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ter, -u— lU. ,1 LU 34Ot�# r1r in r--um r"UL U� <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEER AVE.10 FLOOR <br /> STOCKTON.CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT',OR PIPING REPAIR PERMIT <br /> THIS PERMITEXPIRES 90 DAY3 FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> __TANK RETROFIT ___PIPING REPAIR/krTROFIT _UNDER DI6P6NS£R CONTAINMENT REPAIR/RETROFIT <br /> -- --- -- _.__.i_va T--cotm-r &TELF-WE «-DAI�RIKA- <br /> -I EPA SIT■ N --- CCA6D ._ <br /> I - ' N / MINE <br /> �y <br /> F I FACILITY NAM A�W ✓T�`�t r)rJ I .M 7a1'ZV` - o t 44�7 <br /> •AWRESS 3425 TR4C-11 131.4V-----------• •------• ---------------- ----------•-----------------• ---i <br /> II --------- - -- ----- -' -- , <br /> I L 10=6 STREET CLOT V-04D •.-------'--------••----'-I <br /> Y !�----------------------------------------- <br /> coAST_Pno�Jc.11's( R_,a-cTv _.------------------7'O 'g---- <br /> 7- <br /> • I PHCEIE+, <br /> C I c"NTRAcroR NAIL <br /> •-----------------------•--•-- -- - -.-- - - -• - - - I <br /> I N I COITRACTOR ADDRESS I CA LIC N t C;ss I <br /> ---•--------- --I--------------------- <br /> T +--- ( <br /> WORK.OONP.M <br /> R I INsumit ------------------------------------ <br /> `(�sMC °'_ ` `' - SlG1 .._�.Tuq_�1._`�.�tlC?�Vic� --------------i <br /> �20� 1i1 At pAAvE 3-----•------------•----- -P-�----"g18 PA2.3�4�4----I <br /> 2' P>DNz a 81 842 3?!oD <br /> iilllltl Illiil III 111111------------------ --------- •- SAX............................ - <br /> •! 7ANX IDN I rANII SIZE I GIMICALS SICKED CURRnRLY/PAEVIOU9LY DATE WT INSTALLED <br /> I 39- ;6CIST O, o0o I —V <br /> z 139- on I SxYll <br /> A 139• I L QOA7 I 1.1 L+ <br /> I N 1 79- I S o 0 I <br /> I f <br /> 39- <br /> 39- <br /> P <br /> 9-39-P I AR PROVED APPwVED WITH CONVITION(Sl DISAVVRDV9D 1 <br /> L I <br /> RI ON(BEE ATTACHMSWr WITH CDITIONS) <br /> I <br /> N I PLAN REVI9WOS NAME .DATE i <br /> ---Illlllllllllllilllll�lllllllllllllll!IIIIIIII111111.1111111111111I111:IIIIIIIiI111111111111111111Ifill l IIIIIIIIIIII1111111111� <br /> APPLICANT I'47ST PERFORM ALL WORK IN ACC�DRLANL�WITH SAN JOAQOIN-CGUM OImINANC£S; STATS LANs. AND RULE+•.-PAD R39CLATIONS OF I <br /> SAN JOAQUIN CMM, tXVIRMWTAL fEALTN DEPARTNEWT. ONN&2+ OR LICENSED AGENT'S SIGNATURE CER71FI39 THE POIdAWINC: "I CERTIFY ; ( THAT IN THE <br /> PEAFORMANCC OF THE WOR_( FOR WHICH THIS PERMIT IS IgM=, I SHALL bIOT DOLOY ANY PERSON IN SUCH A PWft= AS TO 1 <br /> 8L•OCME SO4JECT TO MOR(ER'S COHPOJSATION LAWS OF CALIFOMIA." CCNTRACTCa'e KIR=OR SOECONTRXC T;m GTMTtlRi O'BRTIPIES T7R WOR70IR'S <br /> j POLLOWINO, 'I CERTIFY THAT IN 7Sn X]D'OAtdNC'C OF THE WORN FON oAiICH TNTE PNCAMIT IS TeEt7�,_Z..SIiAtt P9tP:/OY PT`7-SONS SUBJECT TO I I <br /> COKYENSIATION LAWS OF ChLIIVRNIA.• <br /> I I <br /> I y_/ 745-0 <br /> I �4�/V r DATB �i i <br /> APPLICANT'S;51GNATV=: SITES----------- --•---•---------•-------------• ----- ----------------------•-• ----------.BILLING IR ION: <br /> Indicate the responsible party to be billed for additional RHD staff.time.expended beyond permit payment <br /> coverage per tank. If,the party designated below is different than theermit applicant, e.g. property owner, <br /> the party must acknowledge this responsibility for the billing by signaturand date below. <br /> Name_____ Address________ <br /> i <br />