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i <br />• t S III 1 , 1 <br />1 <br />304 East Weber Avenue, Third Floor, Stockton, California95202 <br />Telephone: (209) 469-3420 Fax: (209) 3433 <br />TIM PERMIT EMPES 90 DAYS FROM INE APPROVAL GATE 901CATE PERMfr TYPE BELOW <br />UTANK RETROFIT UPIPtNG REPAAtI MORT 1-6)C REPAR/REIROFiT <br />BIWNG INFORMATION: <br />Indicate the responsible party to be billed for additional EHD stats time expended beyond permit payment coverage per tank If <br />the party designated below is different than the permit applicant, e.g. property owner, the .party mast a osis <br />responsibility for the billing by signature <br />- and dale below. <br />NAME G � eO Gt TITLE-:JCrutcelix5r�►�PHONE <br />ADDRESS <br />EH23D= (revised 818MS) <br />• •.- . <br />• <br />T <br />111H <br />ICC Tedmicim's Cerfifioation Number <br />• <br />LJApproved <br />with conditions UMappmved <br />(See�r=nt With Conditions) <br />Plan Reviewers Name <br />DAD <br />� moo. �-• <br />�•:.�• <br />a • •� :, ♦r a -•- .;n �.. - �_ <br />•: •- ra a •n• i • r_- <br />BIWNG INFORMATION: <br />Indicate the responsible party to be billed for additional EHD stats time expended beyond permit payment coverage per tank If <br />the party designated below is different than the permit applicant, e.g. property owner, the .party mast a osis <br />responsibility for the billing by signature <br />- and dale below. <br />NAME G � eO Gt TITLE-:JCrutcelix5r�►�PHONE <br />ADDRESS <br />EH23D= (revised 818MS) <br />