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06/21/2010 14:18 55968814 7 FRANZEN HILL PAGE 02/07 <br /> From:209 967 3972 Page;3/7 pate:W 01201010.97!20 AM <br /> HEALTHENVIRONMENTAL <br /> SAN JOAQUIN COUNTY <br /> 600 East XMIR Street,Staalctm,Caffmutt M02 <br /> TelOPhotte:(209) 20 Fax. (209)46&3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RET'ROFrr OR PIPING REPAIR PERMIT <br /> TH18 PERMIT EXPIRES 1W DAYS MOM 1141 AWROVAL CATS. WCATI1 TYF�s amiaw, 1 �O <br /> ® TANK FIT ❑ PIPING REPAIRIRE'iROFIT [I UI)C N»pAI ROFIT ❑ COLD BTAIRTMVR UPGRAAQ <br /> EPA 91te4 Pi fact Cornact&T <br /> 0 Facility arm e�ptTcne <br /> Addre� Phony c� <br /> 2 <br /> T <br /> Croce Str�eat <br /> Y ownw/oper3 I C-K phon+:# <br /> Q Contracor Name <br /> T Con�ctor Address ' i Phone, 2-9 <br /> A Insurer !10 Cteas <br /> ° ICC Techniclun's Name W-* <br /> T <br /> 5 t lko <br /> Instageea:Name �� t llrat�n Data !2 !r <br /> Tank system work area t o <br /> 0.6.or PUS I" .uoc 1, 1 Tank Siz® Is Stored Currently UST <br /> i Iied <br /> T <br /> A <br /> N <br /> K <br /> P Approved <br /> L APWavad with cvnditlons ol®epprowd <br /> NA ( Attachment Nth Conditlona) <br /> Pian Rawevffim NaI <br /> Gate <br /> API"UOI MT MU-"' 6�F©RRSv�.t;►tORi�1ht45�:�Ari�'iM1iTtft$Afi 'yfN <br /> JQA0U1N CCUMY,RMROr4MG AL HEALTH MPwIST MI-Irl.OW14Wt 4R UCEN D AGEMM SIONA7VW.C8i F1E6 LpYwrrp; y T T Bd <br /> THE pEF�F OF THE vt►CRlt FpR WHICH TH18 PSWIT IS <br /> iXAW <br /> SRZATO w0lll+fER'S Tl�y LAWS OF CALIPORNIA." cpN !9kNJ,NOT LOyAPPY P MSM M SUCM A MANNER As TO Bamm ButLtHCT <br /> THAT IN THE MNV{ TH@ WORK FDR WHICH-0 �RM�jT 19 all 8 AMING HA CC,RTIpiga TWe FOt.Lpy O,. 9 ot��E Y <br /> OF CAUFORNIA.' @D.I L DAPLOY pM"NS SUBJECT To WORKEA"9 COMPMftATfOr4 LAWS <br /> tante S TIQe <br /> LO a I)luumftft� <br /> BILLING IN ORNATtphi; Clot <br /> IndtCeta The responsible be billed for additional I;HD staff tune <br /> the Pay d@slgnated below is di expenried beyond Pott oOMMe par tarctc. If <br /> rQ$PQmIbl1ityfor the biiltng bystgrmtura a te P�w.mh a3pPlteant. e.g. PMP O"Y Omer, the PAY mu*t aftm4edge Stir <br /> N <br /> 11TL1 1 k X42 <br /> AD7pEC3 <br /> snMMATORH f I. . <br /> .` <br /> 6H230036 tlatad Dlt <br /> 1 <br /> This fax was received by GFi FAXmaker fax server. For more informa4on.visit;http;lhvww.gfi.com <br />