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rIr In rL.UUK <br /> • • PAGE 03 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,0'o FLOOR <br /> STOCKTON,CA 957D2 <br /> APPLICATION FOR UN12ERGROUNO TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES SO DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT _,PIPING REPAIRIRETROFIT ,UNDER D15PENSER CONTAINMENT REPAIRIRETROFIT <br /> EPA SITZ R i <br /> IF I PAr3LITY MKS11:- --'•"--•--'-"'-'--'•--•I <br /> i e I AmRRes <br /> = • ,_.,__ <br /> ....__Z�ac1---�--.•cA- <br /> IL I CWSS STRssr ________________•I <br /> I = t -------------••--------------• I <br /> I = I rnm•ER/oaalAloR ---------------•-----------...---------...-------------- <br /> y I I PRONE p i <br /> I + ---------- -- I i <br /> ---••--•--•----•----_....... I <br /> M-C <br /> I C I CWaaA---- ---- �30XLr401 2P� I aeon 0 <br /> ID I <br /> I R I coP ennelve ADWEES ..-' ' --'-• ....- "' I <br /> I T+ — �7.._ _. -me L l a ssc p I nags <br /> IR I INSIDIER - }•••-------•----'........................... <br /> I A I___________________________ ______ I WORK.mm.a <br /> ___________________________________________ <br /> I C I DTiO:R iNFOlMAT201Q .............. --------------------------------------- <br /> r+T <br /> ____...................................................... I I <br /> 1 0 1 .......................................... ................... <br /> I R <br /> --•-II-I-I-I-I-I-I-1-1-11--1-1-1-1-1-11--1-1-1-1-1-1-1-1-1-1-111-1II PROs #-.- <br /> � � ------- _ ------- Z --- - <br /> iI <br /> II 1I I FaR R <br /> ----•-•---- ----'----'--'-••.----•-----'- ..----• •-----••'ra InTANK size <br /> 39- 1 CI=ICAIs ----I <br /> ELOREO COWOxMY/FRSPLOUSLY Oars OST INEFALLrD 1 <br /> IT1351- <br /> A 39. <br /> 9-A139. I I I <br /> IE139- I I <br /> 39- <br /> K 39- I I I <br /> I 139• I I <br /> I 139- I I I <br /> ---IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIilllllllllllllllllllllllllllllllllllllll <br /> IPI <br /> L I APPRav7L _APPROVED WITII cvmTT M(a) !-DISAPeR0yE0 <br /> I A I <br /> PTAN RRPIR3tFA5 NAIL (SES ATTAC4@ WITR OW03TIM) <br /> I N I I <br /> ---IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII1111111111111111111 <br /> I APPLICANT W= PRRFOIDE ALL WORK IIP ACCORDANCE NITR RRN JO.AOOTN MUSTy ORDINNkC6 ' RTATE IANC, AND RDLER AND REWI <br /> SAN JOAOOIA Ili<iOt7PY, ENPTROpA4xI'AL I6AlTH <br /> .FAMMn' QWOR LICENSED ADIM'S SIGMTORE CERTTFISS TATfONS OF <br /> RE FW.LCM3WA <br /> VERrCFC4MCS or 7RE M" POR NRICR=S FERMT IS ISSOEO, I SHALL NOT IT�tgY ANY P67i9wa W °I CERTIFY I I T,,T Ix THY <br /> RP.CYvS S=E=1v NORR}R'S CONOMWATION LAWS OF muroRNTA.. =MhCI'OR's Rmma OR SOSCONTRACT SIC71ATVR2 CRRTIPIES TRE I <br /> I FOULwTAO: •I CERTIFY MT 19 TRS PERPORMANC9 OF TW;WORK FOR ERPLO%WITCH TIQs PEN1'IT Is ISS I RRALL PSR80NS SOROECP WO <br /> TO I I R10rft'R <br /> Oa WATION TAWS OF c,LIFORNTA,• <br /> I I <br /> I I <br /> I II APDLICaNT's SIMTM: rMe et&6PA?eC/ A101y Gy iI <br /> I <br /> --- ---- <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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name —Address <br /> ___.Phone <br /> Phone# <br /> I <br />