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Jul -31 . 2003 1 : 37PM LC SERVICES No - 9642 P. 3 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD FLOOR <br /> STOCKTON.CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 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 REPAIRIRETROFIT <br /> EPA <br /> --- ---- q <br /> 917E • - <br /> IE------E -- � <br /> I <br /> -------------- .......................... PROJECT CORTACT� W ----.��-l.��ID V'- 7•S^V I <br /> F I FACILITY NAME ____-._ ______________ <br /> --------------- <br /> i I e--•.-•---•_J_ 'y_•_l_'!/'?.?'/�,!l�_`f_�}---------------•- <br /> � L CROSS STREET ---------•-----••-----`----^ -•^-- <br /> IT __._,----,-----^•--•--•- <br /> I Y I rAmE if <br /> --•--••--------•----- <br /> LTas,Ta.AcroR rum •-------------------•----- ly----------- <br /> 0 ---------_----- <br /> ___--0 +-----•---_----'� �; .f�/1 V/G!1 S I Ptf�E k I <br /> , N I CCYrIRACToR ADDRrSS - <br /> T + j.0 I CALIC»�j�Fz� �, ; s u <br /> ----------- <br /> A I •- <br /> i STA-tE_Cvn� «- ------------------------------------ <br /> C OTHER IN10RATON <br /> �z <br /> T +----------------- <br /> • <br /> ------------ <br /> PHONE II <br /> + Illliilllllll111;111111iiillllii-••-•--••- I <br /> TAM ID k i IANX SIZE I aEMICRLS SMRW CUMMITt. I <br /> I 39- / a Y/PRfiVIOUSLY DATE UST 1r9TALLED ! <br /> T 1 39- � ��,' 7 oc rA 39- <br /> �I <br /> i N l 39- <br /> i k I 39- <br /> ' I <br /> I 139- <br /> , <br /> *•••I�iiilliiilll:ilf111i'ii� Im' "Illiii1 <br /> P <br /> Iliiiillliiil;ll;illliilillllilllliiiilllflillliiiill;;i <br /> L <br /> A APPRO EO APPROvm WITH COMITZON(S) DISAPPRWP9 <br /> (SEL ATSAC3P�?TT klTri CCbmITIC6a5) <br /> N I PLAN REVIEWERS NAME <br /> iiilllliiill)lilillliillllll„ <br /> DATE <br /> ' WORK ii,lll„,i;llll,iiilllll11111,,;llll,l,llll;,llll;,illll,,,111, <br /> I APPLICANT MUS ALL DPM EN ACCORDANCE WITH SAN <br /> SAN JOAQU CbUJOAQUIN CDiRtTy ORDDQ"S' STATE LAWS' ARD RULES <br /> I N7 y, ENVI3OMM := WAL'IN DEPARTKWr- DIM UR LICENSED WEOrr,S SKIN rM Oft ITTF ES TRE P REd(7i ATIONS OF <br /> PERFMITM OF TWE MORk*%NHiCH THIS PERMIT IS IaSUED, I SHALL NQT EMPLOY ANY ° CERTIFY I I THAT 2WTHE <br /> I <br /> BE SUHJEC7 Ta WORICSR'S COMP P-SQN M SUCK A MAMEP.AS ID i <br /> ENSATION LAWS OF CALIPORRIA." OONIRACTOR, HIRrn�OR S�Ip(-,SIC?lA7VItS CERTIFIES 1ItE I <br /> ING; "I cERTIPY THAT 2D7 T![L PERFORMANCE OF THE WORX FOR WHICH THIS PERMI7 IS ISSUED, I SHALL EMPLOY PERSONS StanCT TO I I WORKEp'S <br /> ENSATION LANS OF CALIPORNIA.^ <br /> I <br /> �. <br /> i APPLICRNt'9 SIGNA7UAE:/!' �s �•�1��� <br /> TITLE CON r ( Off DATE 2::3/, D.3 <br /> ------------------I--------------------------------.----- ----- <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,(.C . S, l: vte eS Address, �,i /tg,e v,� A I'J'Ai V Phone# `9'y ./_i�� <br /> 6 �o� ` �'LW, c fav° ., �u I �� AffA T�,„ 9V 7 � q <br /> b,r r„r <br /> —� �NS �'1-� .�..�1.• � .Mo.,it.�ir, ejN���/►�t� (t9Nrrtst If-'a a a!a/4 <br /> 4?Lr <br />