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MAR-19-03 14:56 FROM:PG&E SUPP CONCORD 510-674-6565 X0:209 942 1697 PAGE:002/020
<br /> SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL HEALTH DEPARTMENT MAR 2 0. 2003
<br /> 364 f'WEBER AVE.3110 FLOOR
<br /> STOCKTON.CA 95202 ENVIRONMENT HEALTH
<br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT PERMITISERVICES
<br /> TMS PERMrr EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW:
<br /> TANK RETROFIT PIPING REPAIR UNDER DISPENSER CONTAINMENT REPAIR'
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<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 applicants e.g. property owner,
<br /> the party must acknowledge this responsibility for the billing by signature and date below.
<br /> Name_ __Address Co_►LC14t'a, C-4 1 9 Phone
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