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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 S�A�&1J32tT�pOR <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> 'THIS PERMIT EXPIRES GO DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS INDICATE PERMIT TYPE 9kLOW, <br /> TANK RETROFIT PIPING REPAIR/RETROFIT —UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +--- ___...,...,..------------------------------------------------------------------------------- ------- .................... <br /> I I It NA 0ITH N 1 1IRWROT CtONTA@P a TNILNVNONA / <br /> I P i FAC........Y NAM I6 �Aai.w w� I . rIwVNONlirw~ <br /> I A .............. <br /> .-r--- .. _r.. <br /> I Q + ....... �r� ! �IF�It:►-Y';! ____ .Yw _....... .. <br /> IC:.YF. «(, 1 <br /> b I dNAAA l9'NK61'C _r`ee .ew w ...w......1 <br /> ........................................ <br /> ......_._..... .................. ... ....ewes.. ..e.w .♦o_...e.w.wr......_.._w.....vl <br /> T I ONNAA/d@NMTOH 1"perry �.. <br /> .Y............. ...,_« �N. .w_ «�c�dt�k . .__ .........!.. .:......7- - , <br /> I C I CONTNACfYIq•NAMIC�C `I� •_ t I 11F10NM N27 <br /> r wl <br /> I N I CONTRACTOR ADUNNpAVp �Y�'9 <br /> I T I___ _.___..._______ -- (,Q �,��_��A—,�......__w...rr-.w_ _ <br /> ---.r»...... <br /> , R I INRI1kKH � _ WONK.COMP.I 1 <br /> A 1--._U-•...............................e.............................................»1___..._.,...._.............................I <br /> I C I OTHI(N INYOkMA't'JON I I <br /> T +--_..._w............................................................`......•---.....♦.............----............------.--.-I <br /> 1 0 1 1 PIIONI N 1 <br /> N +....................................................................................+.._................r <br /> I I I PROLAN M 1 <br /> +---Illllllllllllllllll�ltlllll V III =__�> r�-_-_,_- _.----------------_»._._.._._»:___-__--------.._........ <br /> t I �1= TANN ttl i TANK pill I OM M ICAL6 NTDNND CUhXWftV/i'A8V1tlliltlY I DATN MIT INRTAIJAID I <br /> T 1 71•....w n.¢,�w 1 I <br /> I A 171• I I ,_„_�„�I I <br /> I 17�• I .,,., , 1 - <br /> I 171• _ 1 - <br /> +--•1 I I I i t T rrr T11TT=I i M I M T7"r 1 i T T? *—A <br /> I b II NROVNU AIIPROVKD WITH rONDITIO 1 010APPROVKu 1 <br /> 1 A RRk R99'A1'NMRNT WITH roma-I TTONRI <br /> N ( P W AM"Ill"NI NAM DM'N <br /> +---II►11111111111111111t „ „ ,; II 11,111 I <br /> I I <br /> I APPWOANT MIIAT 1'N,1II'OHM ALL W INN IN AC(:OIIIIANIIK WITH RAN ,IOAOIIIN COIINTY ONDINANCKA. FITATK LAWRAND 1!111,15(1 AND RKQULATIONR 01' 1 <br /> I NAN JOAOUIN COUNTY, I,NVIIIONM%N'1'AG 11NAGTII UNPARTMMM'. OWNI(R ON I.ICRNHBn AOI:N1'(1 'IIONA'I'IJIIN CN81'ill'ilifl THP. POGI,OWINO: "I CRUTIPY 1 <br /> I THAT IN THU PI(HYOHMANC.W ON '1106 WONK POH WHICH 11HIA PKHMI11 ]a IRRUbD, 1 Al1AL.L, NUI' EMPLOY ANY l'640011 IN Hlli'11 A MANNHk AA 'IQ 1 <br /> 1 UNCOMIC IBUpJNCI' TO WORKS1116 C WON1iGA'1'ION bAWA OF CAGIPORNIA,” CONI'NACTOk'R IIININ(I ON BI)N('ONTNJI('rINO RIONATWIR CI)NITIPI610 'Gill I <br /> NOGGOWINQI "I CNRTIPY T'HA'I' IN 'IHk PNNPOHMANCM OF 'THN WORK PON WHI('H I'MIN 11104Ml'1' 114 IHRIiI:U, 1 fAIIAI,l, I1,MI:1IA)Y PNRION® IUN4NG'1' 11'9 1 <br /> I WONKIW I'l 11OMPNNRATION GAWA OP <br /> I � <br /> I I <br /> a...........««.«.» ........... ...................... ....................................»----------_.-. -__-«-»r-+ <br /> BII. LING INFORMATION: <br /> Indic€ato the responsible party to be billed for additional F_.t-D staff time expended beyond permit payment <br /> coverage pair tank. If the party designated below is differ°ent than the permit applicant, e,g, property <br /> owner, the party must acknowledge this rHsponslbility for the billing by signature) and dato below, <br /> ( <br /> Nameek';+" K L_�Address 11111_ , ✓- ` 1 j _.Phonal <br /> Iignature__ "� _ �» 1.114,41 <br /> EH230038 <br /> (revised 1/31/02) S— <br />