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Dec 24 08 05:55p Arco AMPM 20983082ki p.1 <br /> sqN 48 <br /> JOR4Ci! <br /> hFq rk, O,V wig UNry <br /> NQc NrAt <br /> ENVIRONMENTAL HEALTH DEPARTMENT p�RT�ENT <br /> SAN JOAQUIN COUNT t p <br /> 6x0 fest Matin Streed, mala 9 i rah li !,'. <br /> Takphane.(2204) Z0 Fax- <br /> 00 <br /> (209)4SW433 <br /> APPUCATION FOR UNDERGROUND STORAGE T OR PIPING REPAIR PERMIT <br /> nn THIS PERMIT EXPIRES igh RAYS FRW THE APPfiOVAL DATE m01CATE PEjW TYPE%-%L& , <br /> 0TAXK RVM0FrT- 1"PING RFPAMNAURDP T Iliac RERAjRmr ROFIT ;&=srmT WVR UPGRADE <br /> F EPA sm# T 7 r,34 V-L9 3 <br /> A <br /> C F3Ci1tyNainePhone# ze9 $3© $77 <br /> L AMm O b-� rin T c C4 LS 37? <br /> ZCruse street <br /> Y Llwneriopcesm- atat�+ •i Ptlarlt 0 <br /> r <br /> ContrAectorName Qt�I bra M Phone 7Co9S P'ir ,g,siZ <br /> T Conlractor Address CA CA Liclf �'8, ��L pass A <br /> Wolk Comp N •�% ?} - <br /> 7 ICC Teormicien's Cedf c:a6cn NLvftsr �jaC - "' Expiration Date or/G <br /> A TCC Instaater's Certiticatlon NLrnlh� 5 r','�j j t. C, V j Explratlon Case xcc <br /> 11 <br /> Cun�endyiPTevisualy <br /> Tank 101* Tank Size Chamlcale Date UST Installed <br /> iousl <br /> T <br /> A <br /> N <br /> K <br /> P roved with mndiawm ro"7 <br /> L Altvch neltf with Conditfw=) <br /> 3i <br /> N Plea Rsxtewef9 Nerve J&J (?ste <br /> AV;xLMaWT WA7 PERFORM ALL WOalre N ACCORDAAICE NTH SM JOAOM COUNTY ORCINN "STATE.LAWS,AND RULES ANO RIMUTATIONSI OF SAW <br /> :OAGLAN COUNTY,ENvIRONMBVTNL NEJL1.W O£PNRTMINT.CWNER OR UCEMSED AISZN-S liMATU CERTIFIES THM FOLLOWIRG '1 tF11 TtFY!IMT IN <br /> THE PERFORMANCE OF THE WOW FOIL W*CN THIS PERMIT IS 183LIEQ.I DiALL.NOT EVPLOY ANY PERSON IN SUCH A VVINER AS To eECOEME ASiCT FO <br /> woRKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HUMO OR SUBCONTRACTING SIGNATURE CERTInES THE FOLLOWING: "t CERTIFY <br /> 'NAT IN TIE PLKFOAMANCE Of THE WORK FOR WHICH THIS PEON!18 IMED.18MALL EMPLOY PENISONS SMECT TO WORIIEg%COMFENSATION L*ft <br /> OF CALIFORNUL• <br /> lIII. Osb <br /> BILLING INFORMATION: <br /> Indkete the responsible party to be billed for additional EHD Mfr time expended beyond permit payment covwne per tank tf <br /> the party designated below is difiemnl f m the permit applicant, e.g. property owner, eve party must acknowledge M <br /> reVansibitlty for the billing by signehrre and date below. <br /> HAN E ; ate 4-•+ A em,L. TrrLE Aw Aj.0- PHONES <br /> ILI <br /> ADARESS 'f D 2 /'CC <br /> SIGNATURE C;._:' <br /> EH230=8(m-And 1213iffl?) <br /> • i <br /> I <br /> i <br />