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6-18-03;11:17AM; <br />06/18/2003 11:26 209463 <br />;925 551 7888 # 3/ 3 <br />FIFTH FLOOR I& PAGE 02 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3f0 FLOOR <br />STOCKTON, CA 952D2 <br />APPUCATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />•...VAOINK RETROFIT _PIPING REPAIR/RF-TROFIT -_UNDER DISPENSER CONTAINMENT REPA[R/RrzTROFIT <br />-------------- <br />.------------------,.,...................................----------------------------------------------------------* <br />I EPA SI3'E 9 1 noJA"I Cmrm= & TUOPHONE 4 I <br />I------------------------------------------------------------------------------------------------------------------------------1 <br />I P I rACILITY NAME -�1 /� l___I 2P@Tc <br />rDPESS <br />I c I A------ EA--- _33�C) \ "-) DC7---�`�.��:,J---------------------------- <br />II ---II <br />----------I <br />I CROSS STREIar <br />II ---------------------' _...........---------------------------- ------------ <br />I T I OWnWOPMATOR 16A 9— , NQAI aHo� a <br />1---+---------------' ---� ----- t 1a..........�... L9 6's <br />-�. <br />�s <br />N E2 APDRI±R9 -( .•! �( CA LSC I CTa455 ----- <br />-� I <br />j T �................... �� :L_..Sl2r�-f�_ S� ''C`'�,f,J--------_ ---�"_ i -7f- -- -I <br />I R 1 -----r- <br />1---------- <br />C <br />-- - - 7• +" : t I v{ .I:tf / . :auA+.'r' _I -LL =I1� --^t+ ----- - -- -- - -- `----------I <br />Mt <br />17 C 1 DY.....RFQEI.ATIOTI- q\ \ =- 6-f.Y_l4"1%a•�L Jr. Zs -� � .-L'+=-= s..................... ................ <br />1 O l !rte �j- 12HOi41i @ <br />IR+------------------------------------------------------------------------------- ---a, .............. ----------,,........,,I <br />I i 1 PHON'S (� I <br />+---11111111 MI I 1111111 I l l i l I !I WH; --- ------------------------ .-------------------------------------------- .._.--------------.-_1 <br />I I TAM ID I I TANK SIZE I atmMxrars Mp= C pIUM y/h"ti"tr.[W 'LT ( DATE VAT INSTALLM J <br />I 139- I I It�ip�� I <br />I T 139 I [O. I� <br />A l 39- f��,�7� I Z I <br />I N I 39- 1 t2 ,r_2 0 7 I I I <br />1139- I • I I I <br />I 13�• ! I ! I <br />I I s9- i I I <br />T---Illi;Illltllllill111111I1!{Ililllllllllllll;lll llllllllll 1111IIII11l ��'llllllllllllflllllllllll{Illllillllllllllllll <br />IPI I <br />RDPRO1EAAPPROV0 WITH Co[ ==4(E) DCSAPPROVED <br />A (SSE AZTACEPID7 $=H WNDITION51 <br />N PLAN REVIEWEa!�: NAi . =7. <br />*--i1IIlfIIIfIIIIIllllllllllllllll11111iIIlll;i;l Illlllllillllllllll IIIIIII11lIIlIIII MIN I I: i 111111111111111111111111 <br />I I <br />APPLSCAbz MUST PERFORM AM WCRX IN AC003DANCE va- — Z -=x Q wrr ORDINANC'S. STATE LMS, AM RUMS AND 1tDMIATIONS OF I <br />SAN JOAOUIN CQUNTY, 1y1uVIFQNMFSt,CAL ITMTTI DEPARTT`ENf- OWNP.R OR LICENSED AGPNT'-R 6TCSATMM CEi7,TIFIES TAE POLLOWMEM -I CERTIFY ( I 'I.W IN THE <br />DZYSOMONCE OF nM WORK FOR WHICH THIS PMUT TS XSSVED, I SHALL WT E+IILOY ANY P2ZRSON xN EOCH A tVAU R AS TO I <br />l asCOM6 SUMECT To WDPI m' E; Com'E79ATTON LAWS CP CALIFOPATTA' " COYTRACLOR' S HIAING OR SVS=rntPzzn G SSQdAT=. CCRTIFIPS TIM <br />FOLIOWINC: -I CacISY THAT IN THE P$RF0MWCC Or M' WORK FOR WHICH THIS PERMIT IE ISS=, I SHALL SN,= PEMMgS SDE' -E= To J ( WORM'S <br />WMMSATION LAWS OF CALIFORNIA." <br />I V'y"Oe, <br />/tAPPLICANT'S SIMTM. TITLE HATE !1 <br />1 <br />------------------------------------------ ..,..-........... ,....... .---------------------------------- `-----------------------....y <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br />coverage per to k. If the party designated below is different than the permit applicant, e.g. property owner, <br />the party m t ckno ed this responsibility for the billing by signature and date below. <br />D,>P Name _ __,-,__Address6-q7 nukkc/?�'-E_ Phone #(qz_<�� -_i'�>SS_ <br />.. i i <br />