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<br /> SAN JOAQUiN COUNTY
<br /> ENVIRONIVIIENTAL.HEALTH DEPARTIVSNT
<br /> ;94 6 WSVER AVl,I'D FLoOR
<br /> STWON,CA W02
<br /> ADpt.l^J.T1L�n7►DA uNaTrtC.ROUND TRw,fil.^'ri ry�l',',an Pi�,NG a,cvA!a Penin 7
<br /> 7M1 PERMIT EXPIR58 ea DAYS FROM THEAPPRWA4 oAjr-, oo NDl wArft N ANY t,-"ED ARgAA,INDICATE!117.RiX r-YPE PLOW:
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<br /> (� J� CNICAL�'3YDAtn CnRRLN7 L'f!t'xCVICVILY-iyuatra V17+INRTALL➢b
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<br /> ♦•-•;I!::IIJIM 111f1U 111VATS
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<br /> APPLICANT MUST fta?QAN Rpt•MOPX IV ACCO CZ UI IAII JOADUIN e6UNTT OED;VAFI ;;, STAT! WWI, AND AVLII At10 R9CWATja7e; by
<br /> SAN OWAUIN COVNIY, IWIADNNCNTIIL, HtLM 1 t, dkN1A dA trCr"90 AQ VT't 410AM11; L,tp?iPt➢I TMG YatLOilINO1 Cr�rtfY
<br /> 7 tMT U TMS 71APDAAAVor CM THIS mranT ti I090tc, 19WLL NOT OWWT ANY OrPZQN JIM AVCi1 A XUNIII''ar TO
<br /> 1 EDCtit 3MICT to YPliI C FIRM to �,. CtMiM0114 RI:17NV CX "CONYMMO-V 61QM Xf CCR: IFXI:; TNC
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<br /> iOLLO�DIEi '7 CtRti Tt f) H1 ►q , CL DF TMU WMIC11 T1Us FLAX;T r$ II7V;D, I-MbL D414Y O"ImN,T Qu%jrCT TO
<br /> : NDdJlp77'➢ CoilllitslTI SI ijpAMIA .J
<br /> APP4700trr'C VIVATU
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<br /> BILLING INFORMATION:
<br /> Indicate the responsible party to be billed for additional EHd staff time expanded beyond permit payment
<br /> coverage per tank. if h 0y designated below Is.different than the permit applicant, e.g, ,property
<br /> owner, the ledge this respDttsIblllty for the billing by signature and dote below,
<br /> Name Address � -�' � .,.,,..Phone#� Z-' 2�
<br /> Signature 1L T Si�.-�lA
<br /> EH230038 -------
<br /> (revised 1131/02)
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