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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WESER AVE.3'm FLOOR <br /> STOCKTON.CA 45202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT.OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> —TANK RETROFIT _PIPING REPAIRlFiEETROFIT ,UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> I I F:PA SY're R 1 PROJECT =T=ACT G:TELE?=M H <br /> I ---------------- ----------•-----------••---------------------------•------------- -----------•---------• ------- I <br /> F I F:�LI-I-t`.SAF43 u�+(.4-_- L3:FJ-1��__..�W- .... ----E-� ZOO/_ <br /> p , , - -- - I - < - I <br /> C I AI �s_.....__ yJ��(1• Cel_!_. <br /> ----------`--`r''==''---------------------------------- <br /> ------------ <br /> 1 <br /> --------•-- <br /> I L 1 cross SMST / <br /> 1 14--------------------�^DIJ. _.JAL(' YY�E?Yl __ -------------------• - -- - I <br /> T I Om!=/O?M-=R <br /> lyI I I <br /> I-----•-----------------•----------------------------•----------------•---- ----------- ----------•------------•------------ <br /> a i ---------- 10.1E �12-i_LI+.F��-+� <br /> 1 PnOlrn ry / / <br /> it I corn-LACMR ADDRESS 7 f / - -• I_�xiO fl 7�/lo <br /> T ---------------- to 2 .1- -- - - - - --- -------------------------------- <br /> TOR" <br /> ---•------------ ------- I <br /> I s i I iso�st �, noar. cae.9 <br /> IA I - l_` iNYL-QY --------------•-----------------•-•----------•--• �- - •l -`4---I <br /> I C I r/IMR I r=OA*mTZCt ! I I <br /> 1 T ___________________________________________________ ______________ _______________________ <br /> 1 0 1 I PICNH >; I <br /> R _____________________________________________________________________________________________________________________________i <br /> I I I FROrr• H I <br /> I l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l 1----••----•--------•••-----------------•----------------••------------------------------•-----I <br /> I MAZIK ID H I T7LNK SIZE I cj(CmI0ALs STORED CVRMrMY/PREVIEOSLY I DATE DST =13TALLED I <br /> 133- I I I I <br /> I T 139- <br /> A 139_ <br /> I y 139- <br /> K 1 39- I I I I <br /> I 133• I <br /> ZPFROVED <br /> WITH C2`IDITTDN(n� �-DI9APPROVED <br /> A I 71L•E ATTac�Mrr KITH GONO7TTDtm) 191t rV7 <br /> I I Aar RsvTLryMAS NA."'T DATE <br /> t---IIIIIIIIIIIIIIIIII 111111 II II III IIIlillllllllllllllllllllilllllllllllllllllllllllllllllllll IIIII 111111111111111 <br /> ti?LIG�:T KIST ?ERrtl"ALL WORK nr ACCORDANCE WITH ETN JOAQ=l C-ourrY ORD111PX =. STATE LAWS, 711D RMF—' A!ID REGJLATYOISS OC <br /> SAN JOAGCrI COMY, ZN17RcMMIrM HEALTH DEPAM4EIrr. OWNER OR LICENNSED AaENva SIGIL4TURE CERTIFIE& TETE MLOWInoe "I CTRTIFY { I VIAT In I'm <br /> v3sczw'IICS OP VIE v7Or'< FOR HEIICH Tsar PM41T IS 'IssurO. I SHALL N= =CLOY �M PEMQn IN 5uCII A MINER As TO I <br /> 112CC:E SU=C:: TD 5:CRKR'S COK MXTION L\WS OF CALIFORi+TA." CCIM :rOR'S RIRINU UR SIWInTJ%.E cnnl iES .n <br /> I ?ouaa,-naa: •I CERTrF nmT Inr TILE PERFORr.Asrcq OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I MULU EMPLOY PERDOHS SDS,-Ecr TO I 1 MRi✓R'6 <br /> ccs32�LATIG1r LAIRS OF CALIFORNLI." <br /> I 1 <br /> I I <br /> I u2I.ICA:rT,s slGYitTUFtE: TITLE �'_ MTE <br /> I <br /> I <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Address Phone <br /> i <br />