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SAN JOAQUIN COUNTY DEC 3 0 2004 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE.10 FLOOR ENVIRUNPVIENT HEALTH <br /> STOCKTON,CA 95202 PERMIT/SERVICES <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT.OR PIPING REPAIR PERMIT <br /> THIS PERMIT VPIRES 00 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> —TANK RETROFIT _PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIRIRETROFR <br /> __________________________________ ___--------- -P ------e ------D� - ............,-__._-___....____-._.'-- <br /> 00= <br /> TEESPR <br /> I I Fta SITS II <br /> _____________________ _ -_ _ __________ ..___.__._.__...____.____._.-..____�_j----------------------­- <br /> --------------- !1 <br /> vIiaviS <br /> F I FAOILITY NNIO -_ _`_ _�� Iy1 _Z <br /> ------------------------ <br /> ..... ..... ...1 ----- 0__.---V--__ <br /> CI XnaRm 5 l' l/.�I J. __ ------------------------ <br /> -----------------1.7.12.- �'_' L_-.S - <br /> IL I apse STRRST •-----•---'•-----'-----...1 <br /> I I *---...--•-------'--• I Ptd ItI <br /> 1 T I DINER/OPER R <br /> paDKR u <br /> I ER II "t . 1L �1l� <br /> - 3 <br /> • ---------• --- IcA iCLASS <br /> - - ADDRESS - -----3--%S zy <br /> I <br /> --- ---- 1 - ----- 1 <br /> LIMPER <br /> t=rX _( rlal>_� .. X__. --- s._goA_3��_9_ .._, <br /> Q __ moi- <br /> 1 A I'----------- -• - I <br /> C I OnIFR IEbQIFDb TION ------------------ -- __________________1 <br /> 0 1 __________________I <br /> I R .,.________._ I YRON6 3 I <br /> IIIIIIIIIIIIIIIIIIIIIIIII1111111____..___ <br /> RED <br /> T Ax ID 4 I TAMC SIZE <br /> 1 aQ.'1ICAI9 S'Iam GVRRORLY/WR+•VI[ASLY nATE Osi kl27ALLE� <br /> I 119- <br /> IT39- <br /> 39- <br /> I N 39• —I <br /> K I 1 <br /> 9- <br /> I 139•_ I <br /> I 139- I <br /> ---1111111111111111111111111111111111111111111111111111111111111111111111111111�1(i11111111111111111111111111111111111111111111111111 <br /> 1 P I APPR1Nm HITN l OONo7=oI;mr nxSAFenOv¢D <br /> I y I APPR <br /> A I �-" ATrnccaars WxTil p),n11TIam) <br /> p0.TE <br /> Y I PIAN RRVIDNfAS NAME <br /> ---IIIII1111111111111111 Ute' IIIIIIIIilllllllllImIIIIIIIIIIIIII I IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIII <br /> IC <br /> AP?LIcPNr YLST TF]Utl1M ALL RDRK IF AccoMANCD WITH 6AN SOAQJII! UTRiC! OPDIIW= HTATE W".u. WID RDLES AAMRSCJI+\1" OTIFY 1 'DUT M TH2 <br /> AL{qi "DZPAMMTr. 0✓m'D! OR LICENSED "ISNI'a SIGNATURE CnRTIFIas TFC [.gl.LORP'YJ: " DR I 1 <br /> �P02w1lIC6 OP IIn= trArtx Pai HHICR Tlan PERMIT Is Islam. I SWILL NOT EMPLOY <br /> RMII TLT OM O IN sptl(A PAVNen IG'� <br /> P 4^n SUBJE=M VOPREP'S "`W@MTICN LAWS OF CALIFORNIA." WRICH TOR'S RRIT I GA SUED, I'SHALL* MIQNNER CDRTIPIRS TRC 1 <br /> I n0uwmia: 'i CWTIPY naT IN To PGRfOEMG+C9 OF THE WORK Fa M CH THI9 aAMIT IS ISSUED, <br /> I SHALL EMPLOY PEREON6 SDC7ECT'IV 'BEY='R'6 <br /> Co,04SATIO11 IAWa OF CRLIPCRNILA." <br /> i I <br /> Trac /ud - D TE Z 301° 1 <br /> I ADDLICNIf'S SIGNR29RE: <br /> ________________________ <br /> ------------------------- ( r� b ti1DNjrc <br /> �. S�fa�dvlx. P <br /> BILLING INFORMATION: 2 A`1 e Q,, prl�l- l �`' �`�s � <br /> Indicate the responsible pa4-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 <br /> Address_ —._____----phone <br /> 1 <br />