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• <br />11 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WE6ER AVE, 3RO FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT WIRES 90 DAYS FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: <br />,_--„TANK RETROFIT _PIPING REPAIR/REiROW bT ,,,,SUNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+---------------------.........----------•--------------------------------------------- -------------------- ---- ,......-._t <br />il EPA^SITE- _.__- I PR0.7ECi CYNiTAC1 6 ? ----10M------------------------ -----. ............-. _ <br />1 ,f• -----------------------ii .+if:. - sri: -'se a+iirrYrY. —1 <br />>r ! FACXX.xxY' WAN£ USA Petroleum #835 _ I PF1° 1 <br />+- <br />----�--- --- 705 Country." <br />-5LKd.:........_......--------------------------------___...--}---...__.....__3 - <br />L j CROSS STREET <br />+$i- m L--� --------.----_-----•'-.--------------------------- <br />T <br />-.. _ ---"�#_ -Y rps�►oR�a{isades Gas and Wash, Inc. 209)_744-01».8.8 <br />r --' l - ------+ ---_---•-------- <br />a <br />.:_ .--.„ <br />.--..-_y.-. . <br />;- <br />PRCNE#707678-8100IC! COVRi�CTURNaeAlpha Petroeum Services, _CS1DB-Ri--_Q....---__.-.,, <br />&Ams P.O. Box 667z_Dixon,.CA9562�26`s A, HZ, <br />..4�L_I__ <br />It i. _SateFund- I WOKw*-* 1584548.2003___.,• <br />----------------------------------- ^------------------------- s ------------------------------- <br />C <br />------•--• - <br />C OTum XNM3WATSO0 . <br />I _ <br />o »---Contact Person: Bill Hans -------------------------------------- •--»-ori"* (530 30Q:Q .---------- <br />Rt <br />I-r------.vi.i,f iYG ii Vtiss6..............--...-.aa................. r.--- _•-----_I <br />I .. I pKo>Ns i 1 <br />---.1�lIIIIlIlIIilllilll!Illlli?II-••- " '� $ <br />zzs-----------•1•CIiM41CAL9rSTOPM CURRENTLY/PR,EVIOUsi.Y•'+OXTE UST INSTALLED I <br />TANK ID # <br />(_ 1 1,12,000 I ttT t tnla a .. U[Iafft: -i <br />` a I InIparlPd I I lnkanyin 1 <br />( A ` 39 I _ 91 I IntParlP11 _11C1kIIti1 ”` <br />Ix(39 _ I i <br />e � ' <br />-1.4{.1 1 !tl t 111111111111111111111' 'Illlliltf II l I „ II I l.I. 111 1 ,111 I!I ,I, i <br />1L ' <br />L' _ APPROVED AItPROVW WITU C.=1TION'(S) 1ISAPPROVW <br />AI �� 519E ATTACH14 :T MITX CONDITZOtiS) <br />f N I PLAN RNX1i'AERS LOAM$ O DATE <br />t-•-!!!lI11l111111111111t Illtl)111 tl��llIIII1 I ;111,111 m !1. I 111tI IIIl, I -I I I I f I I I I I I 7111-11711 <br />1 <br />I <br />APPLICANT MU9T PERFORM A'e.L yPOR:I Ibi ACCOR.DANCB W2TH SAN JOA(IVibt COUNTY OItDIKAHC6S, 6'IATE IJ1Di8, AND RULES ADTe REGULATWS OF I <br />SAN JOAQUIK 0UWTV, OWZRJKMENTA4 IIMTH OBPAAWENT. OMER VR LXt-aq= AQ'iIE TIS SIMATVIiaH t=t&j;PXI3S TRE FOLW4*A$ <br />I CERTUY <br />THAT IW THE P£RFOMIANCE OF TETE WORK SOR WKICH T915 PERMIT I$ IS8UZD, I 9AAI+L NOT M47LOY " �t�}( J► TOBECOME SU&TSCt TO WORIOIX'S COMPA0ATZOW LAWS OF CALXFORNIA." t0ITRAt-TOR'$ HIRIKO OR $U1� NC SXt�tATUREIES THE <br />FOLLOWING.- "I CNAT.rY TBAT IN TH$ PBMFO)t =CE OF THE LTORK FOR w)i= THIS PEWIT IS ISSUES*& &RALL i'Mimay PzRs0X - VA02CP TO <br />WOMR' 9 CO'dMSATIOK LAWS OF CALI70-UTA. " <br />WilliaLn(' 1 E. Hans, Jr. National Construction Manager <br />1 - I <br />( ABPLIC7INT'3 9i0IJ�tTLff�: �� 'F!7'LB a.�_..__. D)1TE <br />------------------------------------------- ----------------------- <br />------------------.. ----- <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit paymee <br />coverage per tank. It the party designated below is different than the permit applicant, e.g. propen <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />NameAlph Pdtcleti Services, Address 707-678-8100 <br />P.O. Box 667, Dixon, CA 95620 phone # <br />Slgnature i/ .12�X' el V) <br />EH230038 <br />(revised 1131102) <br />