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08/10/7985 2094, Q33 PAGE 02 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL.HEALTH DEPARTMENT <br /> 304 E WEBER AVN.040 FLOOR <br /> STOCKTON.CA 95302 . <br /> APP d D UNDER TANK RETROFIT.OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRE DRYS FROM 0 WRITE IN ANY SMADED AREAS.INDICATE PERMIT TYPE BELOW. <br /> ___— <br /> ____________- --- <br /> RETROPIT I <br /> •___ -T P ET OFl �•UN ER DISPENSERCONTAINMENT REPAIRIRETROFIT <br /> t •.EPA SIT! M --- ------- - •------••_•__• -----•--- _ <br /> *-------•- ---- ----------------- PADJtICT CONsw etaPBo�_� <br /> .'r : rAc3Lizx PANE •_./_r_ _ - �^ ry •� <br /> I A ♦.-----------.. �- ls+rc_f' i-N41...1.. _Y/A_..• 1 PHO.! rO:J- <br /> I •.ADORN....-... ............. G.-k _ •. .L -._- . ..., �q� ��y�;. <br /> t L : CAO-- &TRCET _ - e,�^.j�. ._-..__• - <br /> i T I OWNWOPEXATOR •- ------------------------------- <br /> Y <br /> • -----. -_-.-_ <br /> C ••CONTXACTOA «AM - �,,���],�, Z + tl ---------------- <br /> - ---- ----- ------------------------------------------- ----1 0 i........... ...... t:' .- �1 pNONR { _ <br /> i N COlITA71CTOA.ADDAiLB h I Q�'� _ <br /> tiI+r :... .:_CIL LIC M . - . <br /> A ;----- - --- --- . . . .... • . . F7I... . .ONE: <br /> 1 C OTHER•INFOIt«ATIOR •• ................... Q - ' <br /> Ti---------• --------------------------- - - I <br /> O _ _-•--_-__••..... .................•....-"...------------------_.--.--------------- <br /> iR +------------.......................................... 1 PHONE N -{ <br /> f ...-_•-...__.. ................. ...-------------^----------------•--- <br /> + Il-------• t PNONQ M <br /> TAMC ID ! 1 ,�-T IK !7!lC.. I CltEyjfi�3 STQAt0 CVA�EpTLY/yREV OUeLY ! DATE VST ZNBiALLED <br /> ;{Iit{::9:11; ,:1 71:.:1 rMl.:{i:i1 ..:t:: I I •911 rill!: i ..:: <br /> L : APpAW�RD AFFROV80 WITH CONDITIONISI ,� altwPanovED <br /> A M �S ATTACIIMEN'I WITH CONDITION!) <br /> « • FLAN ARvzEWcR! «AMQ, a� o S <br /> +---isi:iiitltti{il:iiliill�(rf,..l.t ii::lil:i:l:t.i.i:l:i ., l:i�•T i�i�i.'.:� �'.iA''i:i:.. <br /> . •• •lit <br /> 1 ADDLIOfWT NVCO COUNORNTY, <br /> ALL MONK IN ACCOADANCS WITH IAN JOAQUIN COUNTY ORDINANCE$, STAT$ LAWS. AND RULES AND XECVLATIONS OF <br /> SAH.7IN INSVIN COUHIY, 117VIAONMENTAL HCA OR AXTMCNT. OWNEA OA LICENSED ACENTIS EIGNATUXE C%RTIPISS TME POLLOWINO7 13 CERTIFY <br /> TtOLT IN TNI p$APORMANCE OP THE WORK r MNICH THIS SXRMIT IS ISSVRD, I CNALL NOT EMPLOY ANY PgwON Y« SUCH A MANNER A8 TO <br /> I BECOME SVEJNCT TO WOAX NSATI S Or CALIFORNIA.+ CONTRACTOR�0 RIAINO OR SUBCONTRACTING 3IONATVRQ CLXTIFIQS THY• i <br /> ! FOLLOWDIO, mI CEATISY A Or TNR WORK PDX WHICH THIS PYA«IT IS ISSUED, I•ENALL "Loy PEXSONS SUBJECT TO <br /> : MOAKEX•! O9MPSNSRTIO71 i ALIrOR«i � <br /> : <br /> i APPLICAIiT•S S=VATUXi, ^' <br /> 1 TITL TE -0 <br /> +•----""""------------------•------------- ...... ----------------------- <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 <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name1-115D C�;Zf-ft4Address497/ Acii:i c AyP," , Phone#Zo7-L57F-4A-? <br /> Sig ature <br /> EH230038 <br /> (revised 1/31/02) ".t�J Lo�c ' � `a <br /> ad <br /> Cat <br />