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111U(l .LCTuz 11: :;1 Le74bc._46":; I-lt- IH FLUUk' HA. GL U2 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />314 E WEBER AVE. 3k" FLODR <br />STOCK -,ON, CA 85202 <br />APPLICC,TION FOR UN0EFGPt0UND TANK RETROFIT, OR PIPING R[pA)R PERMIT <br />THs PERMIT FXPJREc BO DP.US FROM THE APPROVAL. DATE, pO NOT Wq(TE IfJ HNY S1iADEp AR S. INDICATE <br />-TANK RETROFIT ✓ ^ EpERMITTYPEBELOW: <br />+--•--N-...___ -- -PIPING PFPAJRR3ETF,OFITZUNDFR)ISPENSERCONTAINMENTREP <br />#_--------- ^-- -------------•- ---------- _ AIfuRF;TROFIT <br />1 +----- -- -- ---------`•-- I PRp7E(T conraeT TEII%PPOITE a f 'N !JAI I�1C�15fc- F -.. <br />>;` i FACILITY TiAME --- •------------------- <br />------------------ <br />•--- <br />J ---` - - <br />x ---------------- ---- G-� <br />-- <br />-- - --- <br />I ------_ �p�''�-i ��sP �-----I �01� I �--- fr 2 <br />//�, r _... --- -t- � may, %. �-�q•� <br />JI+ I-C120b5 t'TBSET - ----- --- -•---- --- __:-1V`q 7 �..a�f1-,_- C'Sa-- '`-"-A_.._� <br />x'F----------- �--i�1�,------`J^--- - --- ----------------------- --------------------- � <br />I T I ON,W-'R/OI°ERAT'ORt� ----------_--__-_ <br />1 c I CDn'T1tI:CIOR arJAE t� t,. T' ---------------- ---------------------------------------- �_ SONS C.O(v�T' ---•-- ---- <br />! e ---------------- + - --------- -------- <br />-------------- <br />-- -- <br />Irs I coNTRRcrav ��, "------------- ---•-----------_-_z-I N G. _• ; rtYDNE � /L� <br />1 = * -- - ---•-- � pyo -130 -14o J L°fit c x,52 -i l zI� #- - -- "-�-'-- ------ ---- <br />------ -- <br />a , T>-- --•--f ----------- •---------2??lPQ -- '-CLASS g t c I <br />I � ► orl�,a txPcaly,rloA---.._..----- <br />R I - ------ - -- - ---- ---- --- ----------- ---�� -- -- - -- --- - <br />------^------I-------- ----. ------- - 2 �-- ------ -----I <br />mong <br />I I ----- # , <br />J --`i 13$11111'lx'AN'd�Sb 111iliJllilll!-.---'--^-`------• •____-" ____`__- — __-___- ----- '-_____••_-__ ' <br />--------------------^------- ------ i BY.ONE # <br />TANY <br />I 3D- i IQ%OO� SIS - I'4zrRiI CAL6 STORM EpNC7,Y/PP.�MCUSLY I•DA'_^E U8 !KL'Ty.Li,HD 1 <br />o� H i gl r�c_�n� 1_ J <br />i 129- I <br />J 39- <br />1-p-liil,,Jllil:l I;sl „ Jilll fiiiJll l 1111117EE <br />JII 11111 I ITT Illjj' Ji!, II1! 11;{!I1 IsPPB.(APPRD'JM WTT.K MN*rTIONI A:TA Ed7T WITH CobMIT_: S) DISfL ROS <br />I N I 2LF.N lek�%S2ry7ER° NAME <br />+---111'11111111111111111'ihill it 11111;1. 1111 is ,!i II 1 111111 Illl Illli; J i7lJfl <br />AR'1'LIMP.NT MMT PFiFOFN K <br />i BATT v-OP.QUIN CCLTN7-, FNV FI .OBT•B,'MAL�ivEhLTY� fP1iwTNE�7$AIv J3P.OU:N COUNTY 0$dINAN=, STATE LkWS, PIM RULES )LAID R£GULATIJNS OP i <br />I =kT P_J :rE PEiT1 O7tMP NCE OF THE UWUkF Up LIC:ENgRD A'-MT'9 RIGNA7URZ CERTIF=S TIKE FJLLOWT_31Gc °I CEA <br />BECJN�' 1PORE FCE $'MICR Tr -IS PERMIT I6 ISS, I SRP.T_,I, DILIT F;MP'LOY ANY 1''L'.iS'02I IT <br />'LSF: <br />I 5UBJECw TO WORfWR' S W14P'ENSATION UWS OF CALIFYIRFPIA. , CON YYR2NG 0 $UCl F. M?IyNER AS TO <br />1 I'YILLp{q INGe "3 Cn�. .TIFY TSP.T XIc T.M p2IkFOMW42E OF TIM WCi;Z9 FOP. WRICF. HQS'P a A, SUBCOIP'rR•t CTING SIGNPZ0U- r'NRTIFTE$ THF. <br />iRW�R'S COI:FEDTSATION LP.W9 OF CP=.IFOkD„F,.a EdIT I., Y„g[IED, S ^,�TghI,L )$(�TFyOY PF.'gSONS SVB3SCT TC <br />r`! <br />I 1 <br />i I+P?1ICADIT'S SIGtSATURg, - /' i <br />TITLE 7,„�-_ <br />+------------- -- - R <br />-------------- ------------------ <br />ATE • <br />Blt-l_IN3 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 responsibility for the billing by signature and date below. <br />Name rL $v -I C ht`ct CA-Fvq Address G4 21 CpPtj,-q-- LafJ `151�i-hone <br />Signature <br />EH230038 � pw-v'kGy� ve!- S q' <br />(revised 1/31/02) o <br />I <br />