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V W uDE cutOD oo: bb Z074bbJ4JJ r tr H FLOUR PAGE 03 <br />%me <br />'.9i <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, to FLOOR <br />STOCKTON. CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES RO DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />• _- _ _- • ---_'-'_•X* T-- RETROFIT _PIPING REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIRIRETROFrr <br />yr7-{tI?•g________________________________________________________________________________________• <br />I EPA SITE I I PRO= 03NMACT 4 TUSPRota a ----------- <br />------------------_-------------____________________________ _____________________-------. <br />I F I FAcns=YNME �4 �._ CtLaIS]n \o <br />I L I CROSS NTAEBT 1 <br />1 I •---••----------------------------------------------------------- •---------------------- ----------------------------------- <br />T <br />------•----------- --------•T I OINEA/DPMAUDR I PHONE a I <br />IYI I I <br />I'••---------------••-------------•---------------'•-------------•----------•------- ----------------- --1 <br />c 1 CgI1WAC10R SAKE 1A.'Q�.v1n�a I PARR a- Zo� 3�S-f z !...•... <br />I0 •------•--------------' --- -------------------------• ------ <br />I K I LSWIRAC3]RADDRESN. T--Q`-°«_�A_7__Y3!_ ?! ``" _R ----------------- <br />T_______________....__ y /� p p p p <br />1115M <br />A I ----1. !a_ 5 _i. .AS_ ___________________________! WORK•ClTte__Va;'.3.n�QY_ RR=1Q9___I <br />( C I OTHER IW901DATIa9 I I <br />1 0 1 1 PIMOaE W I <br />------------------- -------..- <br />I I I FRGtE a I <br />_ <br />«--•IIII1111111111111111111111111111---------------_____________________________________________ ___ _ __________________________1 <br />I I DtNt ID E I TNMR SIZE I OEmIcus =AED CORAFRn.Y/PREvi00SLY 1 DATE DST INSTALLS I <br />1 19- <br />T 3P - <br />I I <br />IA139- I I I I <br />1N139• 1 1 I <br />IK139- <br />39- <br />39 <br />9-39•39I <br />,___IIII II11111IIIIIIIIII IIIIIIIIIIIIII IIIIIIIIIII111/1111111111I111111111i mI11111111m in IIIII1111I1i im i 1I111111111111111I111 <br />IPI <br />L I _ APPROVES ✓ APPPOVZD WITH CONDITION (5) DISAPPROVED <br />I A 1 Argc-DIQIP KITH 0XIOITItlE1 � 1 I <br />I N I PWi ngvsatlERa 1911tB / Li � -/,(1 X71-}`-9 _ mlTe (7-0 I <br />•---III111111111111111111111 II11111111111111111111111111 IIIII11111111111111111111111111111111111111111111111111111111111111111111 <br />I <br />I APPISCM11' HKi4F PERE'ORai AIT. WORK IN ACTDRIAI9Ce Wiest SRN TORCDIN Coai=Y ORDINlWCq=, E'LA'IE LANG„ ARD RDCPb AIIII RSI1R+TTKONG OF <br />I SVM JOAODISI tMIFY, ENVIR(MM92VAL HEALTH DZPAMENT, QRNER OR LICEXSO ACEHF'S SIGNATURE CERTIFIES THE FOCM/A9DMG: "I CERTIFY <br />PERaoRMAC6 OF TIE MRx FOR WHICH THIS PERMIT IS IE =. I SMALL NOT I LOY ANY PfiR5QN IN SUCH A MNIDIR As TO I <br />1 A¢CGKE 59DJECI TO "Mm's MKPIna F8Ia9 [AWS OF MRLIFORNIA.• CDNIAACTOR'S RIRIHD OR SOBCONnACz-tro SIRATDHE CTRTIPISS TRE I <br />1 YOVZFESO: •I CZRTIPY THAT IN To PER:GRlID1aO OF TBG NORK FOR. W91CR THIS PHAtRT IS ISSUED, I mAT EMPLOY PERSONS SOEJECP TO 1 <br />COMPENSATION LABS OF CALIFORNIA.• <br />I I <br />I <br />APPLIoxt'R SIaATDMKM ^TITI.e <br />I <br />BILLING INFORMATION: <br />'NiAT IN THE <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 _._ Phone <br />