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s • <br />SAN JOAQUIN COUNTY <br />ENNARONMENTAL WEALTH DEPA►RT%NT 53 <br />304 E WEOER AVE, 100 FLOOR <br />STOCKTON, CA 95202 <br />;,c}i1:4iTY <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR P�(�lnl% �� iJd F; PdT n <br />'41j�{ ruEr""'"ENT <br />THIS PERNI)T EXPIRES 00 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREA` 6DI A E PERMIT TYPE BELOW: <br />_„_TANK RETROFIT _PIPING RC-PAIR/RETROFIT _UNDER DISPENSER CONTAINMENY RC-PAIRIRETROFET <br />__-____•_--'•---------------'------------------------------------ `--------------------- r ------••-----------,---------------------•r <br />( 1 SPA GIT? 1) 1 PRWEOT 0=1%Cr 4 TM- PROra; II 1 <br />i r -------------------- <br />--- ^�� - ��£ 1 ct�1i- -► f��'.----------------------------------------------------- <br />...._.._� UMMfl 2o 368 3so-- - <br />i sq.r- ky 5 LODI� } CA �------------------------------------ <br />------------------ <br />A1- � <br />I L I �nss-sT-------------- - ------ ------------ - - -------- ------ -----•• -----------i <br />smr <br />( I I ---i----- ----- t ----•-------------------------------------------------------------------------- i <br />P!MM <br />l Y l I 047 <br />----------------------------- ----------------------------------------------------- •--------------------------•- <br />--- <br />------ <br />1 TR 1 crfr3A"LOR �zir V-16�o� <br />1 yo 36 z --b <br />--------------------- --------------------- <br />;c:n�s:6-7-7 E tOCO----------------------------------------------------------------DKI`LI�N�1 <br />- _ _.- - <br />IrSURER RAG sr' o I WORY,Ca4F.n 3 yzb8�I <br />O'nm IM.TrT.' k=l I I <br />( T _ _______________ ______-_-___._______-^__--_________-______.-________-____-__--,--------------- ,------------ ""____------1 <br />1 0 1 I PNC.re I; <br />1 r'• ---- --- -•---•-------- <br />I I PRONR U I <br />a.__IIIIIIIIIIIIIIIIIIIII 1111111Jill ------_________________________________________________________-_______---_--_______- -----I <br />1 I TP.U! ID M SIM 1 C104ICALs STDR7:D CS1WMTCLY/PRSv1005LY ( IN= DST 7riL"TALLE:3 <br />I 139- <br />T I 39- <br />K I 39- <br />I 13�• I I I I <br />Ilil 111 lllllllllllllllllllll Jill III <br />I = I 1 <br />L I APPROM APPROM WITM =10MC:I(6) �^ DI3AMaMD 1 <br />1 A I (SEE Ak=c mrr tiro O(W03TI«m) `;-7 <br />2T -%f RLVMMERS lu". <br />( N 1naTe I <br />IIII11111Hill 111111111111111111111111111111111111111111111IIillllililllllllllllllilllllllllllllllllllllllllllllillllllllllllll <br />1L?LIG%:T r=Tr FvrttiYM 1.LL ARK 327 ACCORDANCE WITH GAN SOAQOIN COL'R'I'Y ORDIILI2 =- , arATE LAWS, I= AMM 144 REGJL=Cgu Ls OF <br />1 S.1rr 1OAOUrr COUNTY, MMnza=rrAL ImLTH DZPARTmarr' QMTER da-AICENSEm X'En-a 5LGtL",TURF CzRTIFIEG THE FOTLCW ! "I C rTIE! ( 1 4iwr Irr 7-n <br />msc n:MCR OP :Ire MP -1C F011 MUCH THID PFAHIT IS ISSUED. I SHALL 1x70 I=aPLOY MY PERSUn IN GOGI A MAIn+ER " -ro <br />SMITEC, TO ti•C1Rl0:•IIt'S CObu'1MImXTION LAWS OF CALIFORNIA." MMM101115 ITIRnIa OR 13MCOMACrMu SIQTATURE CCRTIPLRS TEIU 1 <br />1 FOUZ7,-1rxr: •I C[RRTM MVV,- IN TIII3 PERFORMANCS OF TIR3 WORK FOR WHICH IIII'S PETlHLT IS ISSUE:O, I MLL EMPLOY PER•TOIIS S'UBJEer TO 1 1 M11=155 <br />Ma--NSATIOII Awa OF CALLPORNUA." <br />I 1 <br />_ Z <br />:.77LIC.lrT�S SLGYATU}2E; TITLE � , N✓ o R _ LATE -I C= <br />+ •- -----------•------------•-------------' <br />BILLING INFORMATION: VUMV, Al"pD Caw�11-vca <br />33_::- <br />Indicate the responsible party to be billed for additional EI -ID staff time expended beycIQ�erra payment <br />11 <br />coverage per tank. If the party designated below is different than the permit applicant, e.g. pro"rty owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name __ Address Phone______ <br />