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FIFTH FLOOF <br /> I <br /> PAGE A-4 <br /> SAN JQAQUTN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WESER AVE.3"0 FLOC7.a - <br /> S T QCZKTON,CA 95202 <br /> Appl!CATION FOR UNDERGROUND TANK RETROFIT.OR pIPING REPAIR PER&IT <br /> THIS PtRM{f E?CCIaiREg 90 DAYS FROM THE APPROVAL DATE. DO NOT 4VPJTE IN ANY S,'iADEC AREAS,INDICATE PERMIT TYPE BELOVVr <br /> TANK RETROFIT�IPING <br /> REPAIR/RETROFIT <br /> I cYF 1+;f- _ '.-... --�-- (��P-�3 ,. - 5M,•� o©� REPA�IRq/RE-2T•R6-1'OFIT--- ----- � <br /> Yi1 UNDER <br /> it DISPENSEREva SITZ * .,_, - . CQNT�AV,AE\ <br /> NTRE�P.AvIRIFf..6.T.R.�6..h�T.TIPROJECT C1YlAC -----'-.`_......__--_ •------- .............rALIL;TYNAME - - --- - -42-Y � . <br /> `- ...... <br /> --+ -•_• e- -------- - -ADDPE56 PSO S- ---------------------- - ------ <br /> --------------------- <br /> MT <br /> .. ..------ <br /> LT _._L 068 ;TRE _-_ <br /> _._ - -d: <br /> ... <br /> j = i ehrNSR/QpTBR .S-Cl ��5.2C°J�✓ ---- - - - ------ :........--_.-_-.`---` __ ..._._ ..` I <br /> I_C *!�r'r------Z NAME •• _ "-"1 FIIOhrg•p�+ _____________ ----- <br /> - <br /> f # t-�x---------------4%A ' ----�` --- - - -- - -:.._-__._"�'oy'Z.'tw 'j ztL <br /> aACTva ADs+Rss e5�� i --2- <br /> T 1�c - -1-. 1 p -- - - <br /> 11. I Ii+tSL*It_R--- "•_' '�_- P .tee•.-..��i�A«.�1�_ .'I"�i-- ` '] k.037E-1444 <br /> ,,.l,rr?..,3 $��((J� ...__I <br /> �}• r C4 LIC �J /_ s (],u <br /> T I c�T-dER-I"[FOPKATION !LeWc—Q_.'_ •; . ------- f x.e ------------------ <br /> T <br /> _ a I <br /> n - -, <br /> — —`... <br /> R *I1flflfllllll 'II f'dllllllllll ....-.--_"- - - - -- - - -- ----- --+.PNOn-------------------- <br /> TANK775 - <br /> -------- z`< _ <br /> 1 xa �` <br /> 39• +` TANK SISfl - -- ,,..... I_PKotSI <br /> 7 I � � <br /> A 39• '--�.�`.I e� 1(1 i C3i1;MS CAIS ST7REP CtTkREN?LY jPF2.E11FaUSLY '•- ••�•f•7•' <br /> _ fI �j-E'l77 'TAiiSD <br /> N 39 <br /> K <br /> 39- I { <br /> +"_ ° II IIIc Ill 11 1 II dlll I I 1 <br /> P ;9lli filllllllldi1111f1i,1 11 . 1 Illiil <br /> I ANL <br /> f1 <br /> FLAN Ill�llIlflf ; lz DISAIPF+itaIAPPR*Vft APPROVED WITH CON3ITI(88£ 0N(CJkEVtZWCR5 MAMS ATTAIT crEpV <br /> III @1+ <br /> 111i1ifl Illi III I,I <br /> WITY CC,IIIIT'ONS) <br /> �•••ir'illi1�11I11I1111111 I I11 IISi <br /> tillI 11 llallfllltFilY, 11 11 DATE <br /> DRAT€ <br /> I APPLICA.V': MV9T 9ERPCRM ALL W0k'X YN IIflJlllliillii;�If�ii1111-11.1:1 <br /> 5AWT .70AOUIV CON ACGORDANGE WITH[ SAN JOAQL'IN COC x 1 1171 <br /> 1 li i I 1—11171-1.rr <br /> i <br /> i .KAT IN THE PE't � ENVIRflnI-M£ivrAL REALTF3 DEPART'M�';. GWN �M7'Y ORAIbAtrG83, STATE L4�S, +°i7D RETIES APfD r <br /> FCRk'ANCi; OF THE WORT: > >S 'A'SICCi TH);!; 'T IS OR LIC1ilVSED.n::sarrYS tdCNA'i'VR.E CSRTI9iE3 Tri$ FCLYOGi;j,,CTI0h5 <br /> I ad'GOMB 9UDJ*FCf TO AORXER'S COtiPFNaA:IOy LAwS OF IS SSS sV:J. I SXAALL NOS 1EvTL.TY A:dY I C`ERTIT�°Y <br /> POLLOWINIC: ''I 'CRT:.FY TMST IN ZALIFCANIA,I CONTRACTOR'S AIRINr PL'ii5GI3 IN SU74 A MAMMR. AS to i <br /> I WORKan'5 00�!PES!5AT7C+N LANE 3f '� P:F.FORtT1�,NCE CF T*3E 'WORE: FSR WtIICd THIS PERAfIT YgG SSVErcc <br /> 'iq S;OYTP�ERSCVRTNS SFi£c T"IE <br /> d `IFORNI <br /> UBjSCT TO <br /> 40 <br /> I <br /> APPUCANT' F - I <br /> ' S IGNa.'*Iv"REr .. I <br /> Ircxce � 9 <br /> ---------------------- <br /> -- ------------------------ ' DATE <br /> BILLING INFORMATION: - -- <br /> Indicate the 7 esponsible 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 <br /> r✓wner, the warty must ackno�f�fedge tl�lis responsibility far the billing by signatureatftandpdate the ow.property <br /> Address Z S ,x st+a.-2 <br /> .,Spar�s r' Phone <br /> EH2.30038 <br /> (revised 1/31/02) <br />