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v' <br /> t <br /> ®® S I COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"''FLOOR <br /> STOCKTON,CA 95202 <br /> APPI.JCAI'ION FOR UNDERGROUND TANK REI-ROFI'TOR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DALE DO NOT WRITE IN ANY SHADED AREAS INDICATE PERMIT TYPE BELOW <br /> I'ANK RETROFIT __PIPING REPAIRIRETROFIT __UNDER DISPENSER CONTAINMENT REPAIR/RE-TRORT <br /> FSA 57.'11; J� F H(JE CT CONT'V"[ �I L_r.1 HOh7n: I <br /> F PACT UAMB� ,„ ,„y. I'ri(IN F: <br /> C ADDP.E3 <br /> CRUET; �TRtik"I' <br /> ', 'C GWNER/0ia k3:IU+.T[1R ', I%I-1C1PdI: 6 <br /> Y <br /> C C ONTRA1 [)F MAX o r.. ,.,^" ..�✓ ...• I d.lBf t' ft �� - .✓ �'",�?t }) <br /> N ��NTaA< 1m nDe.Nl. -.�t`�r n r rc .,� ."' °>� i°' (1 L-:p� n w. •z' ,;t>±•.•'--- '', <br /> t 171 u <br /> i , <br /> (' D'PfCER SN;.1rIRMATIoN - <br /> 1.1R(aNtt s1 <br /> _..--._. — --- — - -- -- -- -- <br /> TANK ID it TANK [/_[i SSIliTI t 1L3 SiOr'..C, CUF.RLNPI,t':kKFV101-,G'+ PATK UST INSTALLP'U <br /> 3 <br /> A L Arrt"VIII �iTH Ir:rNUI ��l P'APPFI VLD 4- <br /> ----------------- <br /> � , <br /> A IPtl lr L11 r <br /> 9. _ _ __ _ )..IE' <br /> .._N PLAN F.I'VTF'I1L;RS NAPE ; �-- <br /> APPIACAN`I' MCL?T H"PI--ORM ALL 'MURK IDI A(%.'ORDANC 1i 4,1TV `",AN JVAU)UI_,l 1:011PITY JPDINANC L:., 3TATf C[AAKJ' AND Fiill.F.= AND I;!!:U(.AT-1 nNS OF <br /> ,AN JOA[)WN i;OUNT:, it'.Ml.I:RaiNMP N'L'AI, HEALTH DEPAPIVENTI OWNT '_E. I 1 .1•NSE1U THE 1'G1.,1.•OSII:AICV: 1 (-E'RTIFY <br /> THAT IN THE' P'RFORMANC'E ()F IHP. IN(N 1.10? WCIC'H •IH!,'' 11F:RM11' 1.,, I:5U}•.J, I ,[TILL NO EMPLOY AhfY DERSiuN TN 'NUCII A MP.NNER AS TO <br /> 3E.COME: SUBJECT TO WORKER'S C'4MPFNSATD,)H LA�nL9 OF CALIFbRN?P." (_ON'CRA(-'T(flR'S HIRINU OF. StiBC'GDPTR.AC'TT.NG ST GNATLJRF. C['.RTT_FTFS THF I <br /> r,'E:(ePI.FY 'PHA"" S;.N THEI q14 P11Fi '-1OR. ('n1 'N111C1Pi I•HIl� EMPLOY PERSON.^, UBJEC'T TO <br /> kv(1R7 f R' I OMPF:W;A IQN i:,AS!i QI,' CA1,J�uRN A." <br /> APYiY(`AN'C :; SIC;PJA( RE�,'fi�i%�_-.w� �" -- .�..-._ .______. ________._._—.__. _. C1'I';�. .� I.='� d��.I:�':G°' .I^'j�/,..�°�.;.r�,DA•IE �s�-�,.� �f� <br /> l� <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EH® staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name ; ' Address) ;y � p Phone # <br /> Signature r r <br /> EH230038 <br /> (revised 1131/02) <br /> 1 <br /> Z00[2] 'TVINHNNOUTANH 11V1 TTOTSMT6 YVA 90:60 90OZ/ET/VO <br />