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02/24%2005 13:47 2094683433 FIFTH FLS PAGE 03 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WU0 AVI=,3M RZOR <br /> STOWON.CA ASM2 <br /> APPLICATION FOR UNDERGROUND TANK R@TROF7T•OR pjpNG RERAIR pERMIT <br /> THIS PERMIT EKP{RES 9D❑AYS FROM THE APPROVAL DA rE, 00 NOT WRITE IN ANY WADEDAR 4rk 1NOnAT$PGRMiT TYPE BELOW: <br /> _ _ _ — _TANK RETROFIT_PPM RWAIPMEfRORT_UNDM DISM4 CR CONTAINMENT REPAIRIRETROFiT <br /> -A- - ------------------------------ ----------------------------- <br /> --------- • � <br /> E -- T C—YACP� <br /> -- --- - - ------------------------ <br /> lv <br /> imAvacm <br /> r - <br /> a+--------------- ^--- P} S a <br /> ---,------------------------•------ �-- <br /> I• i CROSS STREET . ----------- <br /> r -----t <br /> • <br /> i <br /> c'�e�xXMz NAM _ � N Ls ,1 5 T I(�UC- i o„`.--------- --------'*7-/r cT1'a -q - <br /> t T �--- REM------ �-- �-x--„�4_3 .14f-t- CALK-S-.- �-(-1 V`Cp~�_,_CfrA6S A 7-�tCTi----- <br /> a -----R �cacM ! VLe__M -------�©V-3 c�_7_------------------do ' ' `= "_# ,3$.1 3 - <br /> C asfffia INs�xaTTgp r- 1 <br /> r <br /> T +-------------------•------------------------------ <br /> R +--------`-------------------- -----•------------_---------- ' <br /> ------------ ------------------------ ----------------- - - -- - � <br /> 35- TE r YD 4 r ' —� G � : CAS STORED CMMTILYIPOMOMLY : MTS 06R �AL <br /> L8D <br /> _ 1 _ <br /> t A 1 3Y- �5 ©E7 <br /> 39- - <br /> '�-•'-1111{1111 ii:,...,. r :,rii rrr i,ri i,iiirr, iii,..., , r '- <br /> e ;ii ii rr, ,.{{ir„a ri,iii,{ii�,riiri{{iiruirr,.i,ii�r„•.,•. <br /> P i � <br /> L t App APPROM WITH OMITICM(S) DTSAPVEpV� <br /> 1 A 1 — ATT Leffler T KM Ccnmaw <br /> ' N PLAY RQNSUM DATE <br /> 'i---•.r. •• . '1111tii1t• !t .11 1!1!111 S!I 111::1 ,,,�� ,,, ��r ,. ,rr��r, , <br /> 1 APPLICANT MU9T PERFORM ALL WXX IN A0007dDW= WITH SART JoAQU1aT t WAZY jelftn =S, STATE LMS ABG RpL$$t AND R@l:OLATIaiB OF <br /> SAN JOA=N COMM, ENVIRaQF MM RMTH DSPA . Of=tt aR=.===='6 S.T=ATM CBRTIFIEB THE EOLLONIYOt •T eERTI-1C <br /> TEAT IY TSR VIMPORIMCE OF TIM MOR!FOR /Gild Tfas v=NrT IS Is==, I SHALL NOT z&%,0y Agr FIRM Y9 SCNZ A tOJEM AS TO <br /> BEObME SO ML'r TO VOR$RR'S CO)NSATI(S LAW OF MUPMMA_* ms's XM= oR 809OCN'FRAM'IM6 SIaNAMS e"131"72*6 TM . 1 <br /> VVIIAMIYa: •I CERTIFY TEAT IN THE MWO MAMCB GF T= a=pa 3P.YICB TFIS PEW? IS ISSN, Y SttAtt. EftETC�c .san-crF TO f <br /> 1 ikN=16 COMPLY wim LAMC OF MIPWIA.” <br /> s "� <br /> APBLICANT'3 SIGNATURE ' TX= � � DATE �_ <br /> +---------- --- ---------------------------------------------------------------------------------------- ......... <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHQ 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 /> Name— /7' ( Address 1 O l ©,c S� _/�W "Rhone <br /> Signature <br /> EH230038 <br /> (revised 1131/02) <br /> 2 <br />