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-SAN JOAQUIN COUNTY <br />ENVIRONMENTAL, HEALTH DEPARTMENT <br />304E WEBER AVE, 3"P FLOOR <br />STOCKTON. CA 85202 - <br />APPLICATION FOR ONOERGROUNO TANK RETROFIT. OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES W DAYS FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK RETROFIT,PIPINGREPAIRJRETROFIT —UNDER DISPENSER CONTAIN RENT REPAIRI%7ROPIT <br />I I -RPA WITRa <br />P I FACILITY NAM <br />I.0 1 ADOPESS <br />L I CROSS STREET <br />I T IpM1>PtJOP@RAT <br />I y <br />I -PROJECT CQNTACT A TELEPQWW a <br />I PIRATE a <br />PRpR6 a 164-5—qq _ 0-313 <br />i e }cut?R CTqE ---SAN9'_--_"c15cY'�!L42_�25`�:wY�__�_C�`?""il-f "rl2L__-__....__�_p _RONIR p..l:�S _ 3: IQd3 a � I <br />caamhmllup <br />N ---------- ADDRESS --i CA LIC • <br />I R I I-EORRR <br />I A I- ----- _________SL1.1L- <br />C 1 OTHER INFORMATION <br />.. .. I PRONE 9 <br />----- _------------------- —------ .---- _--- .---- —------- _____-----_--_---; <br />+1 I PHONE a <br />••-II{IIII II V IIIIIII I1f1II IIIIIIIt------------ —-------------- _-------------------------------------------------------- _-------I <br />I -TANA m a I TAH& SIZE MCNICALS SMRW CDRNSNTLY0REVXWELY I DATE OST INSTALLRO I <br />- <br />! T 1SO3P- <br />A 39- �• i <br />I N 13P-�- <br />I K 139• <br />1 OP- <br />I 139• —i'—; I I <br />+--•1111 T;III:Ili'IlfII II !III I11 iIt111II:IIIIti II,tIN II L L'IIII Itt ltllii l if tl7l IIIIIIIIIIi t:tl l..tl1{ til ll!Itti-T;T „ IT'�j,l'I (I <br />PI <br />I L I APPROPEO WITH CONDITION(S) +f` _, PISADPROY® <br />A 1 E ATTACHKE MTN CONDITION3E <br />1 <br />I <br />I' N I PLAN RRPTRPRi9t URNE <br />DATE <br />----I M illilTl li ltt:''I 11.: pi1 APPLICANT HOST PERPWiWWe,< IM ACC CE TN SAN GOXOMN COUNTY ORDINANCES, STATZ LAWS, AND RHES AND REGCI.ATIOWS OF I <br />SAN JOAOCSY LTRINTY, ENCIRONMFNTAL EO:ALTN pHNER OR LS ceNEP.O AGENT'S SIGNATME CERTIFIES THIS FOLLOWING: 'I CERTIFY <br />THAT IN THE PERFORMANCE OF T= WORK FOR WHICH In$ PERMIT IS ISSUED, L SSA.. NOT PDt17,0Y ADY FERSat INRCCH A NP 1`S16R AS To I <br />SECONE SCEJRCT Ta WOK='S COMPENSATION LAWS OF CALIFORNIA.• COMRACTOR'E HIRING OR ^uPBCOWTRACTINO SIGNATURE CERT!sx F.s T'U <br />POLLONINS: "I CERTIFY THAT IN WHO PERFORMANCE OF TRE WORK Fate WHICH TH[S PEtMIT Is Is==, I 5.+..+ EMPLOY PERSONS SUBJECT TO <br />WORRRR'S CWP XiSATIWI LAW& OR CALIPOwa'. <br />I <br />J. InTITTmnN(n nTnnnm(I jI TT110 <br />?itis i <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 applicant, e.g. property <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />9 sll a - <br />Name &W, (e Sb -+&g 54S4P p ddress U iKN /%Z 5J�e Phone # ` 63 -• 213 -b 03 `� <br />Signature�� <br />EH230038 <br />(revised 1/31/02) <br />