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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 9O4 F vvEB6R Ave.,2"FLOOR <br /> STOCKTON.CA 95204 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT.OR PIPING REPAIR PERMIT <br /> TH!6 PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATR. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW. <br /> _TANK RETROFIT PIPING REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAtRIRETRR/OPIT <br /> 4 - 1-LFA VSITZ i _—__—/_�_—_—_/_�__.r. -- —_ PRO=, CONT= 4 ?M&MONE 4 P. y r'`��1�}p,5�7/-ry{OL�0 1 <br /> 1 F yMIL-17e NY — /���V _(o0Z -_--_-----_—_----FISONB 4 C201), Z3 471S -1 <br /> I I ! PDDR=SS —_�?[ _- -- LYS f G��� i-! <br /> 1LiCMSS "FTT <br /> I -----------------------___�-----.......«—.— ---- ------ ------------- — I <br /> S ! OIftCIk/QP=020R ► A f <br /> I x 1 8 P PJrz5T ecA r Pi2U.DacT$ L.LG t to4q-33 35 <br /> xrrr%-%cAna► _rAi r --r�_v_�r�oN M it +� SY f 45_ + rNae>E n ¢.}567-t-400 <br /> i I CMCP AMRW x'45 1j, J�E y 1 u.�� 017A;�16 I -k LIC X 67ee t elaswa A <br /> r <br /> R ~INsu" E3RAK10E - C14A FN ITL I t.J,jU _ ; NOR1c.ccr>y.tl pg�( J8503 <br /> AI------ -------- - - —_ —1 <br /> C orm 1wv10?J TI0N i <br /> It -----------------------. <br /> TANK ID a rnNK SIZE I ChDaCALS STOM CM1tWr"Y/?RV4OVSLY i MATZ UST YNSTALL= ; <br /> ! T 1 39- <br /> x <br /> 9-o l 3D- <br /> iNi 39- I 1 <br /> IK139- 1 t E <br /> 1 <br /> 30- <br /> 39--1 <br /> 0-39- i ! i <br /> --kill I W Ii111111111:1111111111111itillililll;ii;litlil:111111171;I1'ti:i1111i11i1111ii11i1111iii1iill111111i1i1f11tll1tl!Illi <br /> I ? i f <br /> 1 7, 1 v ACMom rarrxwBO WITH 0=I^_'I091M 1113PI OM t <br /> A 1 (^u �NITM CDN!.T=iOtSl <br /> 1 N ; PLAN 71EVII:NEIL4 N?�R �1 Q M=- <br /> +—:I: <br /> Y.� <br /> +----:I;IIi111111i1ii11{i:Itl:i;:fi' f ill1111i1111H ill 111 W I Lt1;:!'{i1:t11:;11Jill Il{tIllIII 111.11111ill I X1111 (11!111"II iii <br /> 4.e�� Grp d t�c.ye.�a e,�. t er tci� -molworo — 0 ca- i <br /> APFL%ooff t97LT PEREW ALL�% V ACCOPMICS XTH !SAN JOAQIAN CMVry ORO U" 6TATS Iritis, RLI SS AND R.�(,a11IMCM OF <br /> SAN �-akCL`IN I70VITY, 2M/IAO*0,IV1L HOL711 DUMT►fM. MM CR LICIDNED AGENT'S SIQAZ= CERTIFIES M3 rMIOXMI 'I CM71ri I THAT IN TIS£ <br /> Tr3tsWv;tt9t¢ Off TIIG Wornc " KKXCH TKXZ yL'WIT IS ISSV®, I 6t01L'.,"O'T I1Sf°.AY AM rLasCei IC. SUOi A twuBSt A9 TO 1 <br /> i SECOff 1IT8n= TO NORIM-S COtermwIOM LwS 0_*guar w%h.- COSJTA)=W,L Imam OR 6OBCONTRAM"G 3X w"Im cvtTlrses Tic <br /> 1 lOLIMNGI 'I Cl!"IFY IMT 114 TAI P£R5OIQ0=OF THE MOR1c !DR mKica TKi3 nm4n It I.^,Sm, I Snst,T EMPLOY F'uzom III78.1P.CT TO 1 WORM'S <br /> COb ' ZATION LAMO OG CALIFOPPIA•' <br /> S I <br /> 1 <br /> 1 <br /> s APPLICAVV S Ssc winks: , �BaTI'II,E p R6 , e-DOg7, anre 4'0-04 i <br /> 1 <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 -rA1T ep4yi". jm"rp►LAddress 1963 AAJeMu-.F- 10 6-g 46G- Phone# d1*)6Z7-44,00 <br /> sisr�ns <br /> 1 <br />