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u7/CJ7/ LC1C1J UO.OCJ r-lr IH FL_uuK PAGE 03 <br /> '3 2/Y <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3�FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THI3 PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW; <br /> —TANK RETROFIT _PIPING REPAIRIRETROFIT ,UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> ------------­-------------- ---------- ------------^--------------------------------------------------- ------- ------------- <br /> 1 EPA SITZ li I PRWECT Q=MCr &TELBPRotB # I <br /> ---•-------)---------------------------------••----------------------'---------- <br /> I <br /> I F I r r <br /> JA ------ ---------_�- [5__ i�� �l`�(�---- ------• <br /> I C I AtAPERs 1,,, <br /> I = <br /> -----------------------yy __l'k-11� Y`C�1i.1a 1A--------.�_G GLL---------------- .-----------•-------------I <br /> I --- ----^--------------------------- <br /> I <br /> ---------- ----- <br /> I # I <br /> JYJ I <br /> -----•----------------•----------------------------•• ---------------•----------------•-+ ----------•------------••-------------I <br /> C I C'QT71.3ACIOR rMAE --t-- <br /> 10 <br /> 7-- !(.-�y7 ,;- jZ /__ <br /> ----�lliZ�l4 - - ... - {.z <br /> I o •---------------- VV11 -------------- --------------- ---- I <br /> I R I CCNraACTOR ADDRESS --p CA LIC # CL43� <br /> I r ZU -�'1� Y1lYLL� L � - - - - -------------- <br /> -------------------- <br /> R I L'1SLRER [,►i:G (..� `�J L`t Z I FORK.CmB-# <br /> I A I------------ rS�-R� �S`�M_r � .i }-+ - ----- --------------------------------- <br /> C <br /> ----- --• ----------- wC I CI� IMTaULlTI@7 I 1 <br /> T --------------- ---------------- --------------------------------------------------------------------I------------ ---------- <br /> 01 I PS ; I <br /> R ---------------------------------------------_______________________________________ _______-_-._-____-----__.-_________-__ <br /> I I I non e I <br /> + 'IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII-___.-_-___----__ ------------------ _--- -1 <br /> I T&IW ID 4 I TANK SIZE 1 CtCMIr,L 3^o RED C4RMTrLY/7Rz'-viooSLY ❑ATE tisr INi;TALLED <br /> I 139- I I I I <br /> I T 1 39- <br /> A 39- <br /> I I I <br /> lNl39• I I I <br /> K 1 39- <br /> 39.9-39• I I I <br /> I 139- I I J I <br /> *---IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIiIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII <br /> IPI I <br /> L I APYRU= <✓ APPRM'ZD WITH =MrrION(S) �^DISAPPROVED I <br /> A I (SEE AT ao= WITH CONDITIoto) I <br /> I x I ALAN RRVIawLI s NAME+ ' O I <br /> ___IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIllllllllllllllllllll 111111111111111111111111 <br /> I I <br /> I IL-PILG•vI MUST TERFORM ALL WORK na ACCORDANCE wITR SAN JOAQUIN cY.nnriY ORDINRDfUU, aaTE LAW-,, AND RULZS AND R=ILA'1095 OF <br /> I SA.v 70AWr-n CO@IIY, SNVTRCUM?rAL HEALTH DZPAR'j%=, 7NER oR LICENSED =xva sleaTURE CERTIFIES THE F0,1 O1 ! "I CERTIFY I I TRAT IN THE <br /> m3soR.wMCS OP THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NUI' ErULOY AM PE"Cw IN EDCH A MANNER As TO I <br /> I RW--'S SUWtCr TD WORKER'S CUKIMBXTICN LAWS OF CULFORNIA.^ MVM CTOR'S RLeula OR SUBCONTRAC= SIG21ATURE CMTIPIES THE <br /> POUZWnM; ^I CERTIFY THAT IN ME PERFORMNCa OF THE WORK FOR WHICH THIS -MtNaT IS ISSUE., I SHALL EMPLOY PERSONS SUHJE= TO I I MRXER'S <br /> CC4'?ElLATION LAWS OF CALIPORNIA.- I <br /> I I <br /> I <br /> APPLICANT'S SIGNATURE; <br /> I 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 Phone <br /> i <br />