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11/07/2002 11:32 2e946c34.:,3 FIFTH FLOOF. PA;+-�E C12 <br /> SAM JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 3G4 E WEBER AVE.3pb FLOOR <br /> ST( 'KTON,CA 9$202 <br /> APPLICATM FOR UNDER13ROLINO TANK RETROFIT,OR PIpN3 Rj:pAfA PERNEIT <br /> TFli5 PERMIT EXPIRES OD DAP S FROM THE APPROVAL DATE, DD NOS'WRrTE IN ANY SHADED AREAS.IND.wOATE PERMIT TYPE 9F_r C)W: <br /> �1/n�TANKRETRC)FIT�PIFING,�REFAIRfRETRCFIT�UNbERP18PEAISEtC71�TRINruIFJJTREP,gIa/RE7'RC7FIT <br /> !-'_�-----'SII'----C`t'l �•�� t �'-tI_PRO,TE�T C--- -• __ ------ --- -------------- ----------- <br /> . <br /> e + FACILITY NAMr I^�. -- } .. - DT i SL ON .- --- --_�zr oruE # _KU—KXr• 2,00)-�Ea$-® - -� <br /> SB- s-r -- ^-ING.r - -- - ---^---? a----lm.41 <br /> ----- <br /> ---------------- �� �� P <br /> --- ••3 LOD! C-- ejS�' <br /> II C>n�s S-,PZEr _______ ________ <br /> �+ rG -- ^- ----- -- - ------ ••- <br /> S --- -- ------ --- 6 V -- --^-- -- -� <br /> IT I o►+araRlo�>urtATca - ---••- --^•--- -- - - +----`------- ---- I <br /> I-Y-*-.----,•____,•--- 1���iµ��U 107 �-o 1,S. I 1 Nr— _-I PROVE # ��_-/-'-)0-�•----'(•�-----•--/-�^�•7-.-,-- <br /> C I mbTltrCTOR DTrJAE V,4e �4 -----------------------fr - .-___ ---_rte_J'�65 0IG+ V <br /> f x I --------- s--r--- -- -------1----X-ON` IDN S'r-� -�t-A(7- __ t-PataE -------------- ----- <br /> - -- <br /> 1 +- �. --- ----- - --�JD_ ` �'q- ? y�.D�7S s '�45 rr-s,zC 2�3�04 I cl s-" !� 4A- �41G <br /> fi `t Co l hls - - ----- ^ ^. _•w! -------4------ <br /> I•,- «-------------- ' - unto <br /> RI-- - -- •- ---------------------------------------•-------- -^a- - -- - --- - - ...----f >2I€n-- ¢`-----------I------------- -----I <br /> IZE <br /> j`-` II!IIIIIIIIilfir�'IlllililIlii'------------- - ^•_-`-- -----..,_-'--, ..___ `___I_BHONS-)i- __'_____---- --•"-----^� <br /> ��nnyyrr P .. <br /> 3B- CD-I3G-I j �O,OOO SIS. 1 Hlrws SIGRF33 cvRR r 7rY ItSc1aI r •rPTE --. ��verwuRD- <br /> 1$• y V I 119_. O INF S M TE <br /> I A I 3h i lr I• l <br /> -r 1 �1 Iii , � 171 I ;II , <br /> I <br /> z <br /> A ! 3PPA01jED APPROGEb"rim comST w IS) •! nlSFio9R�� <br /> I W Z'Lm xxv,EWERS MAME A F 99IT& CMMITIONS) , <br /> �-";1!!IIIl11111111111i1,11!Ill i! 1:'!11,1 Illl; <br /> Milli <br /> I Ilfiil + II;II IiiI31 k i Ili€ ILII 131 ! III I;lIi111 <br /> i A-PAS,ICANT MIST PEltrPRK ALI, WDRK ihCLU <br /> Ak=NCE W37d$Air Jo"73•.N MuNTY <br /> SAX j4AQUYR CC1afTY, RrIVTFiCIhTIEi]TA.: REALTY_ TJEP riGINAx7=, STATE bisY+5. Ah'1S FTlLES t4kTD RI+G'3LKTI.�xrS GF <br /> TJ'ihT I?7 :REE Fk^R Q.43n- � �p E GWML F L3E? LIC.E'NSED JL:;EXI•9 !pj:CT2,.TU� >rERTIPX9,y5 THE r_-LL0j1L-40=- "I C£R <br /> I 9EC61i7h' S'I72.TE�"." To WOR 47MpE675AT7.[7)J 3.7 WS OF ICALTFORWI: �� I55UF.G, l SFIP.LL E7t77' BFlp oy ANY X. EO, IIT 6=A 17?,Ish'ER J15 �`QT_Y= ' <br /> [STK T A. C'�77;d1:CTQ8'S :?IRnM OR bMCD"'M_ LCTING SIGNA^TM4T <br /> I WOL 8R'sGe "I YSATIox TEF._ %ra CA-- ro2*OrAn4te OF TEE WVA;N FOR ISH:CY. TH-9 P % ONS SL JF Tk3T I <br /> Y3pAlfG[i'S eC'i:PEDfSRT:G3P LP,S$S L>r' CP_',LFdSfTS^:A.�' PERMIT I£ Y_SUEL, aFTk7.7, t$I']F'I.L1Y Pe.,'i50N5 SCf9.I5C; TC I <br /> i ; <br /> f <br /> APPLICANT'S SIWAT'MEe <br /> TITLE <br /> RATE <br /> +_-__.....--------------------------------------------------"------- ^-•---------`----------- --•" -- <br /> •---------------,1--------- <br /> BILLING <br /> ------- <br /> BiLLlNG INFORMATION: <br /> I I' <br /> Indicate the responsible party to be billed far additional EH D. sten time expended beyond permit payment <br /> aaveralge per tarok. If the party designated b6ow is different than We permit applicant, e.g. properly <br /> owner, the party must acknowledge this responsibility for the billing by signature and date kmlow. <br /> Name >=•F. l OT? 5 4S Addre s ASv Phone AC. yke'014 =.. <br /> Signature <br /> EH230038 <br /> (revised 1/31102) <br />