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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUN COUWY <br /> 394 East Weber Avenue, r,Stocbftu,CaMmia 95292 <br /> T bone:(299) -MO Faz: )46&3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THS PM1 EMIREs 90 DAYS Fra TWAMWALMM 7E PMW TYPE <br /> L]rANKRETROFFT L6ocm3-mRwrRcnT <br /> F EPA Sib Prrsjed CarTrad&Telephone# <br /> A <br /> c Fac�ty Name Phone# <br /> L Address lh- (� <br /> T Cross Street <br /> Y <br /> tarot Phn#2M 864 <br /> c rn <br /> actor Name # <br /> OIna <br /> N CbrAddress CA!is# GassTAr ` �#c i 's Number Date <br /> T <br /> O JCCs Bon Date <br /> R <br /> Chenicats Stored <br /> __Tanicsire_ <br /> Irate-UST.InsUdled <br /> T <br /> A <br /> H' <br /> K <br /> PLkppmved witl fps ved <br /> L Wdh Co ) <br /> A <br /> N Plan Reviewers Name Date777 <br /> j <br /> AMJI, Aft'At4 W _ .... y mrnnran crn�Sd 111115 ADH2__ A®B _ OP^W4Qt <br /> - - ..... ._._ <br /> CXXJNrY, AL I EALTti_... ..-.__.. C71AA X82 OR t Af n'S SK 7URE THE _ _. 9 CERTIFY THAT IN <br /> THEFEWORUNIMCFTHEMMFCRVV&iK:HTHISPE1'ilfaFTISBMWISFWLWr ANY Of MS iA AS70 W=W5M3Vr7D <br /> ,VMOM COW9MTKW LAW C)F C)ONrRACMMHRMGOR&MCDYMACTM SIGIAMRE CEIZIFIM 7NE FML=14a `ICBMFY <br /> IFiA7�F7}E C FTHE FOR 71-US RMW S mmm.I9—wLEwL0Y GCTo noN EAvus <br /> CF CALEVIMM' <br /> e Tdie <br /> BILLING t TM: <br /> Indrcate the responsible party to be billed for additional EHD Mane expended beyond permit payment coverage per tank If <br /> the party designated below is Mment than than permit applicant a g. pmpedy owner, the party must acbrawledge, this <br /> responsibility for the billing by skjpakffe and date'below. <br /> Fes:: � , TFILE � , �+1����� Pit # <br /> SIGNATURE l <br />