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JOAQUIN <br />ENVIRONMtNTAL HEALTH DEPARTMENT. x.. <br />FLOOR <br />APPLICATION FOR OPERGROUNP TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRE$ 9Q DAYS FROM THEAPPROVAL GATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW- <br />.—L—TANK RETROFhT X_;P[PIN6 R 'A]R/RETROFIT ,^UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />*-----^ � ---.�..-------------'`------------------ - <br />---------------------­---- <br />t-VPA 8YTE # j PROJECT CONTACT & TELEPHONE# /�Q /� a /%/� j <br />P + PACTLITY NAkW -(.�C NV W - .� r------ J =-BRO E_ :.L Y �_M�L.i_Y_ <br />i. L +—CROSS 6TREE --- - — ---^.�'_ —-...._»��_—_ ...._---------—------ ------------i <br />iI b--_——............-------" --------- -_-_e.. <br />I T I.QWNjIR/6P6RATOR i PHONS`# ^ <br />I T s t- vTo A s <br />-I <br />! C . CocJTRACTOJi!> ^_ «i•'.5 S <br />--------------- s PMJ�`i. <br />! N : Cala2xhCTOR ADDRESS (f�_/ g4 _ J(R7'l� �a Q 1oZ J CA LIC 0 1 -If-10. 0.; <br />---- ---- ..___M <br />=------- s ---- COMP.# 1 ai _afmc <br />C i Comms INFORMATION j { <br />1 T ra----------_­---------------------- —_^*---------------^----------....,..w---------------------------------•-----1 R J <br />D, <br />t PRONE 4 <br />- ! Pt40NS i <br />I----------_•-^---- -------------------- --------...<.... �__---•-_-- <br />_-_-------------------- <br />1 f TA= ID HE <br /># j TA>ZK'SIES CMICALS STORE4 cu8i2EDtTI.Y PRmousLY I DATE i7'ST INSTx.L= I <br />j <br />t T j 39- <br />A 39-i <br />I N j 39- I f� =�_I <br />{ R ! 39• F i <br />i t 39- <br />+-P-iltfiiltl:JiiiJlijfJJjiJjjiiljjJ:!i;l::it {.ii Till 111J j!III:1:115 ll.JJ S.4iJJlljill-I:;i{ill jjjltt:l:iJ�1i { jj jli.tti <br />! L I APPROVED APPROVED WITH CONDITYU4(8) AIS"1R04ED. <br />�. A (SES ATTAMENT WITH CONDITIOR6) <br />I N PLAN P iEwatt6 .NAh18 DATE ! <br />---1till jllliil.Iit: J:liiii.i;i l9ililslll:I!l::iiiil {'�!' Iii.H ,tIl1i;:ll:Iff{iI Nllllill11111:Illll{!!i{1i{;lllt::l:; mi ,illlfi <br />I APPLICANT FWST. PERFORM ALL NORJC IN ACCORDANCE WITx gm C'Ot In COUNTY ORDINANCES, 6TATE LAWS, AND X=r. AND Rfi6OLATIMM OF j <br />! SAN JOAQOIR CODcOTTY, 27TS/IRONMhRi2141, E➢LALTN DEPARTMENT. OWNER OR LSCER618D AWMI' 3 SIGNATORB CMIPSES TIS FC=01=I •I CER'T'IFY <br />i TMT I.N = QHRFGMMCZ OF THS WORK FOR WRICH THIS FERMM 1T 26 ISBDED, I'SHA&L ROT EMPLOY ANY P=CZ4 IN 6UCR A MAMER AS To j <br />! RECO}tiL m3JECT TD woaxER'6 COMPENSATION LANs of cAtzFoRWzA." CONTRAC cSt,s uzR= OR SCBCONTRACTING SIMMTVR8,CJr ttZFiss T2?9 j <br />FOLLOMJIM: "I CERTIFY THAT IN THE P13RFORMANCE OF THX NORM FOR MJIICH TNIS PERMIT I8 isSDED, I SHALL EMnLDY P@RSONS SUBJECT TO ! <br />! WORRRR'9 COMPENSATICU LANE OF CALIFORNIA.• I <br />1 ! <br />I 1 <br />! <br />a. InTIT:Tmumrn nTff111Ml1P3i TY1rifi <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 <br />owner. the. party must acknowledge this.responsihility for the billing by signature and date below. <br />t <br />Name ddre'ss (08b QUiVl�l �tU. ^— = Phone # <br />Signature : ; E:� .0 - <br />EH230038 <br />(revised 1131/4) <br />