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0 New Facility Lit Existing facility <br /> '' 11 Pu, ""Ij-, <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> t afr;a�y��mr <br /> i Arco AmPm <br /> :tens3u;as City �iatCt ze <br /> 255 E Hamey Lane t cxti CA W.._.� 95240 <br /> APN slupltmwronteirf <br /> A <br /> Tye of Service 0 app4ra%,on far C3 Cdnsuttaticm C7 Change. ar r carter 0 ftepa s zw Wtemcxlet t=8 r°rthcr <br /> Requested OM41ing Permit <br /> Comments <br /> Nead to reptarx Q7 and 9105t, annular settasors I,t3 3o4 serew. drain valves ;n 87.1, 87-2 ,and 91 W(A- Ms flit Cap an i75L roixket. <br /> _...O .. . � k _ ,.— <br /> tr ?nrttj� pt+J+"i!irrstr� ;9r IUCPriSYPS:1teNir j },rk <br /> i <br /> i c,€tt ar.....rk�._.�a iY..,Y..w�� �� .r..,' __,,.L_._..r �...7......�j t x� r t t •:�>»a.,t r vw�.wr� E�r��i;ss_�w,...�E3 AtYRtt�+eCt <br /> I, ret�reutK! <br /> 4�uimR Patty 6aohly Owner 0 raualy caritaci I U Pr<ruety GWrser 0 contfAiui ILI Amnited <br /> h v <br /> Vfu Name I Wit ra lve it If Contractor„ ind"tc type and totnse nurntKt <br /> o Address City Stato ZIP <br /> f'hunA Pho„t Tfmal <br /> . 04 <br /> Il6 7f <br /> kP <br /> S„i,r, Paity 0 fa[,li 0wrie( a I ryL t <c C7 Propkitty OwrKr__ _ ConT*Jcie rrst Name t 35i r amr if ccPtr icto? tndacateW-?t and I:CenRo numlt�.r <br /> BZ Maintenance 433159 A B C-61 040 <br /> Add <br /> ft% city <br /> RhO rr _ ' <br /> PO Box 933 W acramento CA <br /> P , _ # <br /> h Email { <br /> 916 3"71 2380 Margret -msmitho_bzmaint,com or Er*ly emdy@bznqticam � <br /> C] Biiitrtg t*arxy L7 far,7lity owner L]fiatel;tY Contact C� rtr perry�w,k r Cl{.13r3t4'¢!Ct@F � Asf haler�t <br /> _ - )Vr <br /> List h t � frtryYName Vie6 Addres, _ i :ty State 28 <br /> Phatsfi Ar9Ckrst` ry:,e 7 <br /> MiLING ACXN0WLEOGkMENT:1,the Understgurd property or bustnr=.i4 rswrer, operator or atuihof4e4i agent 0 s4mf acknomedig4 t? OJofr ­fZj^R� <br /> speitIQIFN OWN IMF NTALHKAIfHDERARTWNl hourly<hargasasiattated wit hthis;wcj4ttarl0hotywt`lbebibfr�itcrmtrcu ntytsusrnw�� r+stztlen:,t,±� 4�c thrs ��� <br /> ferric <br /> t ats ca ttfY that r have prrparcd thin a Wation and that the work to hi?pertoitnMt MI be done 6n a<rordirsrei watts a)$ SA*4 XAQUtN COUNTY 'D ; <br /> 4;andarrfs, STATE and PEDERAL Laws <br /> APFUCANT'SSIGNATtlt s _ �7 ' _ 'rR '. OAT( ` <br /> j <br /> 0PPOPFRTY7PU51NESStWNFA <br /> tt APPLICANT IS not the SILUNG PAR rY, prool of ,)UMOraZAti E <br /> AUTft4tRt7ATJt?N Td ESEL£�iS£ tNfL1tlMATftTX�;N� apt k tr „ati•I �= 6r Op° tlior of the rx0party10c4l0 st WC ?,40ve sate AUess, 4ff"bj aaLt+mak*the <br /> re,came of gny In'd .il` rsuttt, W,, rm w-,v, ka Mie SAA 104QUI IN COUNTY E'WRONMENfTAi,WALE <br /> t7t IiftTN9PaK i s a a . rtsrl at to sarrt y< , r, <br /> 17 C t€1rit3ta rl <br /> I <br /> h: <br />