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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E wurw AVE.r FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK AETROFI�.OR PIPING REPAIR PERMIT <br /> Tmis pERwT'EXPvMS go DAYS FROM THE APPROVAL DATE..DO NOT WRITE,IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> --TANK RETROFIT ___PIPING REPAIRIKZTFt;FIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> --------------------------------------------------------------------------- ------------------------------------------- ----------- <br /> I ePA SITR N-___.___.._______ <br /> pRWECT C*nACT TELEPHOWS It VAVRIW <br /> - - <br /> -------------------------------------------------------------- -----------------*------------------------- ------ ------- <br /> F I mclury WM A r-6,0 rj ............. ............ <br /> A •--------------------------------------------- <br /> 3425 -MACI 13 ----------------------------------------------------- <br /> --------------------------- j.:42..................... <br /> L I CIRIea 6MB7 C�%,(G42% V_C7,&0 <br /> I ----------------------------------------------------------------------- ----------------- ------------------------------------ <br /> T ownWomMATCR mom N <br /> Y &P ................... <br /> C I CONTRACTOR NA14 I PRWE <br /> ---------------------------------------------------------------------------I-----------—----------------- -------- <br /> =1706CTOR ADDRESS I CA.LIC I ; CWS <br /> T ...................................................................................................I------------------------- <br /> R IN=Mq I WORK.LV04P.0 <br /> A ............................................................................................................................. <br /> C <br /> T(O M-TA.. <br /> PKI 06 --------------------- <br /> 1 08(8 <br /> 3-----•------- ! ----- ------------ <br /> up- - -A 9 150 2- 1 VHMM 0 842- 376c <br /> ...........Fe�'X­_ ­....................................... <br /> HIM------------------------------ <br /> I qllll�l (1 <br /> TAM TO N I TANK SIZE CHMICKLS STCUD CIJA?JWMY/PnVI0VPLy I DATE VOT INrTALL90 <br /> r='T 101 pp- <br /> 39- <br /> 11111111 MIMI <br /> IPI I <br /> APPROVM WITH ITICK(SI 0IrAVVR0%r40 <br /> A I (SEC ATTACHMCWr WITH OMMITIOWS) <br /> N I PLAN REVIEWERS twe DkTz <br /> 1111111111111111111111111111111 1111111 Ltill 11 111HIMWIIIII lhilll 111 till l111 1111111.11 till 111111!111111111111 <br /> APPLICANT MST PERFORM Atb W=X IN ACCORDANCS WITH SM JOWTV COUDITY OPOINANCES, STATE LAWS- AND AM RSMA ZON <br /> 9 Of <br /> SAN joWUIV =&=, tXVIRoNMWAL IIBALTJS DCPAATMM. OW M OR LICMED ACEWT'S SIGNATURE CfATIFIW THE POLLCWINC: -1 CE;tTIrY I THAT IN THE <br /> pERronmAmce Or In WOR_( RM WHIcm THIS PERMIT IS 16SURD, I SHALL NOT EMPLOY ANY PERSON IN SUCH A KANN= AS�o i <br /> gzoaz sm"cr To woxtmR-S compa=TjoN LAWS or CALIFORNIA." CoamcToz-8 I(IRM on EMCONTRWTIM GIMATUM CaRTIFIES nm I <br /> FOLLOWING: 11 CERTIFY THAT In TIM PMUVRF&4M OF TW WORK FW WWCH TRIG PL14MIT IS IBM=,.I SHALL RNF.DY PrOONG SUBJECT 70 I 1 WOMM'S <br /> CotMENghTION LAWS OF CALIFORNIA.* <br /> 5 <br /> APPLICANT'S SIGNArju! TInA e5L4 DAIS -7-47 -OZ <br /> .................. . ........ ........... ................................................................................. <br /> ----- ----------- ­---------------- <br /> BILLINGIN ORM ION: <br /> Indicate the responsible party to be billed for additional END 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 signatur�and date below. <br /> --Address-- Phone# .. <br />