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MAR-07-2005 03 : 19 PM COLLEEN 344 2644 P. 01 <br /> 03!124/2005 15:3Q 209433 FIFTH FLOOR • PAGE �2 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 704 a wasp AVE.SW FLOOR <br /> ITOOKTON,CA xU93 <br /> APPLICATION FOR 11NOGRGROIAIO TANK RETROFIT,OR 0I1INO RP PAIR P1RMR <br /> TRIG PERMIT EX03AGI10 DAVE FROM flys APPROVAL DATI, DO NOT MITF I-4 ANY SHADE'ARCAS INDICATE PERMIT TTPG 6116OW <br /> T_ANK RIP_I+OPIY_., _F_PINO_RI_P_NIAImrROA.xIRalNG..-•R-CON..T_A:_IN1.1 <br /> --- --- -.__--^------------ <br /> -- ---___ ------ ----- PxeP 71- <br /> ------- <br /> ..... . . ............. _____ _- <br /> fr <br /> .77 <br /> Y <br /> : ; sx9'ee asalm: <br /> I x 19RPII/wGEA1oN �j. - '--'--'-"----- -- - <br /> C r &Amon RANI «. 1.. ... __ I -------- <br /> 9 *-----------------` C, --- <br /> P Oawmcac. Ln0 mu P L[L G <br /> C OPBER '-inma.YTiaw�V'yT a_�+. `I- L11�1�]p,}•�---17-------- <br /> - <br /> - tt — 1 <br /> _J I --- + ' <br /> ••••i els" yi - •• i ®1 M lYnate:azr/.AeNSOtlG1Y GLxb TbYT <br /> A I 1 - <br /> :N6IA'rLmPP ! <br /> A ; 11• �! <br /> I ■ 111• <br /> R 31 <br /> i 11 -- <br /> 9I- I <br /> ^li IIIIII II III If <br /> R , <br /> 10�`� <br /> /P /� /�AP R:aI 9o[miE[ONf6ll mi1APPGWID+---�••l+ ,'l+ <br /> I x <br /> PiiA 11YSMtu++••Y :.:: 4 �/1 b (!a <br /> A11L_"Wx NV1x OINOW ... rpbm IN AOWR9ANC9 Ni:R OAN 70ASII3R COVRIx <br /> e1A1t�G:TmAQtTRW?` , W0ORYA£A:TR 96PARTRWNx. CR LICPNSEO CWAT9AA.. 19+I NIC7.A1LN <br /> AcEn,,z SIMMRI axlp;IS IOILAix : "S CNC1P <br /> [RY0WI,cW9o= O.4n %VRA PONNECT [7 M3, <br /> lI :M 1 "IL 601 "W7 ALP( PERSON V N01 A++NmNEA AN -VeAcomn soAlEcr m LroRlml c COMPffieAxmR WS 9v rwI"INTrroYPIA.• CCxrnAO. ,, Rwlxc a sw00Axa ;W xIAA193I eEAY_s:p =z <br /> P�LL(ri+[1M• wt CIAT[xY YRa= SM'1rIR PERlCAMAxCE Ox sea MOM ffpt NAS[x M11 VE T 19 ItH=, 1 SW L 9RP10Y FZNW Y AM TO <br /> ROP]!RR•8 xP1Pxx+ATSOm WN8 OP CulAft+n <br /> , APP',ICmxT ^ SIGt111'J'AI� <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. It the party deslgnatsd below Is different then the permit applicant, e.g_ property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name i� YP Address 02 Phone <br /> signature <br /> EH23003$ <br /> (revised 1131102) <br /> 3 vmr SW1T�t 14000 6PW )NSA -Ib2cj-cVK <br /> 3 volip � C4P6 i l l-T Cc p <br /> 3 Pw <br />