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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />30s E WEBER AVE. 3— FLOOR <br />STOCKTON. CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERAIR <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE DO NOT WRITE IN ANY SHADED MEAS INDICATE PERMIT TYPE BELOW'. <br />4-TANIt RETROFIT PIPING REPN <br />R/RETROFI I _UNDER DISPENSER CONTAINMENT REPAIR/RETROFI�T <br />TTI j V I'�'V p`i'y YRuden I1x1'Al-r' Y rXa PN�we "_�_U� <br />! FAt :.ITY NAMR UC a � 1L 1 �� � 1� OCR <br />r <br />AUURE5, , It I/Y rT iz;sa 'R� PHONE R ). `4 (�6_r��l �S <br />. r't�A lA_ 'Sbb`rrr--V„111 `70C fh__.. <br />"ROSS STREET <br />aI`NNBRC:p�MRA R� qPHONE <br />Y ONTEA YHOREjf' •C <br />••ONTRACTO'i NANIS �n TLNV QLJ� C.4aoU <br />oron� o-lru;�Pon PRONE <br />1 'ONTFAI^M1 P AUURRSS <br />�. <br />INSURER <br />A- <br />A <br />�'�IQ lt. ` .� len % A ' " 1�--- <br />n _ NURR. CXWP," <br />' UTHBR !NPURNATION <br />( 1 -.�] (� - -- PHONE R - <br />fY v' �'!R I 1q.STAN, <br />5 21�0� N NI CAiS Je Fgn MEERNT:.Y/PRP.VT0OS:,T - .. . <br />T lY J I'IS �I e 1 (p1.pTE UST IN.ST`A(..I.,® <br />A lY. V n l^�1 n:1�MFY <br />N lY- <br />19 <br />19 <br />P <br />AAPPROVF.II APP4UVA1. "I'. <br />t�(1 <br />N PLAN REVIENERS SAN,�'. NC, ISEP ATTA(l1NRN"IX7,,"r WilITIUNSI OISAPPROVE0 <br />GATEAPP <br />SAH yJVAOIIIN IVUNtY YOPN A:,:. NORM :N AIy'URWNC'R TNIEN Sµ N�AG11I ':MINTY �:RUINANCES, STATE' :.ANS, ANO RUES µp REQILATIONF UY <br />8M Up THE NOR- <br />HIM ..I IYNSEO AUENI'•S SIUNATURC CERTIFIES THE YU:.:UNf NO: <br />THAT Ili TEE PERPOR KORKH OF THE ,pRR POR NRICN TRIS PERMIT I::F:.S1U811, 1 SHA:.:, NOT UNATOY ANY P <br />BECUIRi NGB -T t TU CERTIFY <br />THAT <br />T CONPENSAtIOF :ANS OF 1 CERTIFY <br />W:.:.(N1ING: '! f•EFTI PY CA:,IFORNIA." C'ONTRACTOR'S MIRING OR SUB �IN IN SUM A MASER AS Yp <br />TXAT IN THE PBRFORHMM OF THF. HOME Y�): MHIC'H THI:: PERMIT IS ISSUED. SHHAAINGEISIpp1ATURRE�$RTSFIES THE <br />WFEEP •S CONpENSATI ON .ANS UY JC -IFORNIA UIWECT Tp <br />I ITLE O� UATE 1g33-oe <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 res nsibility for the b ing by s' lure and date below <br />( ',' (� lsQllO l i rip_ C'-aY�rLL�iy�r, � r+ <br />Name ;1 I J it3Z Address�L,,)61q:1 r --K (;Q_ ej/Sy��� Phone Do) <br />EH230038 <br />(revised 1/31/02) <br />1 <br />