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FROM: MANTECA LIQUOR AND FOOD• FAX NO. : 209 239 4550 •May. 18 2004 12:35PM P1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> JW E WEEK AVE,3m FLOUR <br /> STOCKTON,CA Y521Y2 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES SO MVS FROM <br /> Me APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> .,. TANK RETROFIT -✓_PIPING REPAIRIAETROFIT .... UNDER DISPENSER CONTAINMENT REPAIRIRETRORT <br /> _.. ....._._. 043.0&. <br /> jI RFA ---R # ! PRnmrr ra..... c ......INR#Jee----an ---- 76-- 2b19 m' �1�I n I- <br /> I R I rmMITY 10M I I I GLYI`71-1( I—i D1r 4�FI)f5 c( 20 4 a-3q-'f5S0 by TL '{• <br /> FH Ra # <br /> A______________________ __._._.. .. . .. ... _ --------------------------------------------------------- <br /> r,.--, <br /> - <br /> Aon q o tJ 533 tom.. <br /> r,.-- .......... `�3+ =r�t�1��^ Man 1?-ccs... 9. <br /> r. I MMES RTRSer .,_)o �3f• �. <br /> T ,....--------------------------G----------1-----......... .. .. .. .. ..-------I. <br /> 1 T I ➢NRRR/orRrtAT➢R 10-0-+ .Lan d 43 Lt.. m➢NR # Ce.l t <br /> Y I _ q-7.�5-2.�i,q <br /> I c D�M'INC'IOR RAIR l .kued �Vi Qi f'1P��i YL I I T ' i (I. I <br /> 10.11—----------------------------------- ---... ._. . ..( -- ✓rlel -------------1.a9-'fb -.2o�!- <br /> --- <br /> I H I °"'"�""""R 1 b5�- l.n cern e 1 a'T° # S l l b l 2 1 QAR9 A P+A ZL <br /> I R I ISSORER .. 6 Tu d--------.. .....-.. RJRK.CIXK ,» 0 061q I x-7003 <br /> 03I ) I.._.__..__....... ...,.........I.... 1 <br /> I c 1 ansa n7owamm .............. . . . . .......... ... <br /> I r,-----...__.._.. I <br /> I DI <br /> I I I eases# <br /> ___11111I11111111111111111111111111---------------------------------------------------------------------------------------. .. -...1 <br /> I I �^ TMK W # I TANK SIZE I COCCAIS STORED C=MDECY/911IIpI0 7 I DATE DST ISSMILS; I <br /> I 1 39'... <br /> 1 71 39 !�h old .. <br /> 1 A 1 39- Fi#M _.. L.. .._(.!_ I ♦�i n'_sel I —_., .I <br /> 1 1 39. I .,...._.. ....—I I <br /> 1 1 39- <br /> *-"Illlllllllllllllllllllllilllillllllllllllllllllllllllllllllllll 1111111111111111111111111I111111I11111111111111111111111iii111I1 <br /> ILI <br /> R IIIIIIIIIIIIIIIIIIJI)1 1111111111111 11111I1;11 � ®wrrN aRR3TTTrARl9) _ nxane3x➢v>m I <br /> I NTRI COMR,ONS) 1 <br /> I A I AL'In�T�1' <br /> I I IyII II I II 1111 NAl6 '711-1 <br /> It <br /> AIa <br /> I IIIIIIIIIIIIIIIIIIIIIIIIIIIIII1111111111111111111 11111 II 1111 illlllllllll <br /> APPLLCANS'WDF,f eY3tPORN ALL puAR IN nCWR4MUCE wT'DI SAR.TOAQmTa cnurrr➢RDISWNC88, STAIR Yaws. AW➢ ROL#S ANO PEc,'tR,ATI(RS OF I <br /> SM OOAQVDI CO➢IrM1', idi9m(WM1Nmi. HRA➢IN➢SEARIWffi9T. 0i 11 OR LICENSMI A. r'S%TgIATRRR CRRITFTRR Tia FOIZOMR➢: •I CRRTIPY I I TIWT IR THE <br /> PPRFQ]Q')M®OF TAR WRR FOR BRIM TRIS M MCI IS Ts.:VEI), I :AATI,Imr RYIR ARS FRREIXi IN sucS A RANUM n 1U I <br /> 1 Mrs R ,,CT M ROMR'S NN MTIQN LAWS OF =.TFORNTA.• MWORACTOR'S HIRIP5 OR SDSWNTTNCYN3G SIF TIRS CRRTTPTFs Tia I <br /> 1 FOT.iCAI1NE: 'I CERMW THAT IN TIM RSRFOIMANCR OR.TRE WORK FOR MRCII TIS PEWIT IS T,:^•OHO. I .MTs W OY ibis spe.1EC^C gyp 1 I KORKSR'S <br /> CCMPITSATI(RT TAWS CtF CALIFORWIA.n /L////' <br /> I AFPT,ICANT'S SIGNAIVRS: ( _.. + TITI$ \4Ij/l�.(I ��/,., nArR <br /> -------------------------------------- --- - -----------'-------------- --'-----En ;nom';..... .-' <br /> ate I. Se-1,dduu 4A opb3"+= !+ - --- -w #vI I �fY <br /> BILLING INFORMATION: t� 4d V V-u. <br /> 2 • '��' nay �- 6-e-, A S4* <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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name... � nd l t,. ---Address-190 644et a�Phone#_13q-4550 <br /> i <br />