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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE. 3" PC OOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROLNW TANK RETROFrT. OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APpRCvAL DATE. 00 NOT WRITE W ANY SHADED AREAS VIVICATE PERMFT TYPE SMOW: <br />TANKRETROFIT---- <br />PIPINGPIPINGREPAMIETROP!T_--__- <br />T ---- <br />DISPENSER CONTAINIIIENT REPAiRoRETRow <br />— -- ----------------------------- <br />EPA SM 0 PROJINCT CONTACT -------------------- ------------------_---- <br />-----­------------------------ _ -------------------- ------------------------ I ------- ---- ------------- <br />S --c's -------------------- 1 -7 <br />­__ ­ - --(g I ---------- <br />--------------------------- ----- ------- R -- 0 -------------------------- ------------------- <br />C ADvarss <br />75 <br />-------------------------------- <br />L CROSS MEET "z -e- <br />--------------- --------__------1___--'_.„____"_'>--_.-__-_-__-_--__-______®»-_-__ <br />T OWER/OPERATOR <br />y PiMN- <br />--_ <br />- 4 <br />----------------- pq2- -7 <br />---------------------- <br />c4n"'RACTOR KAM _7_1_i�� <br />----------- <br />-------------- <br />AMBIASS --- ----------------------- <br />c"'t CA LIC S <br />------- ------------------- <br />R <br />A <br />WCRIC COM P <br />?®_e__- <br />-------------- - -------------------- <br />C OTHER 1XIAURMATION <br />­-------------------- ----------------------------------------------------------------------------------------- <br />----------------------------------------------- — ------------------------------ -------------------- <br />----------------------- ------------------------ ----------------------------------- <br />TANK `e0 0 .CHM: $70AND <br />CUKR=M,v/P9ZVI0USLY I DATE 1161 Imnnm.i. <br />T : C�� - <br />39--- <br />aI 39- <br />'Z <br />39- <br />v <br />APPROV3n WT M CWDrTj0=(Sj <br />ATTACHMENT WITH CONO.-T--ONS) -2 <br />N PLM REVI]PORS "IMM 0(. <br />CAI DATE <br />RI LIC MIJST PERFORM ALL WORK jS ACCOSIMM VM SM jDAOUjN ODIRr <br />,y O=X,=CZ, S� <br />,ATE L&WS. AID R i-WrIONS CF <br />ALTr D89AWM=r, OWNER OR LY 190 A2=T1S SI TURN CS3tTjFxzS we <br />SM JOAW2Y COWrf, 3"'ROMMIXTAL Up ULES AND R W <br />Ftsi.- 11 CTYTTFy <br />T "r 'no PnPOnEMWX OF TRE "M MR MMIC” THIS PERMIT 13 ISSUED. 11 SMALL NOT =4PWY Avy PERSON IN SL TH A MAMXER AS To <br />REOOM SURTSCT TO WMXRR'S COMPMSATZON L"S OF CAWFORIII4, - COSTRAMIII 313trNo OR &tMCOWTRACrT= SIOUATUQX CnTIFIES THE <br />FOLLOW MG' ®F COMFY TS&T III THE PARTURPIMCEI OF TXB WCIRK POR iffleff 7913 nMtT IS ISSUED, w4vLoy Potsoss StWECT To <br />MOST= C3KPWNMDK LAWS- 4F CALTFORRJA. <br />APPLICAIT7.s sTG01QIvTvM"j <br />NX'rm: <br />L <br />------------------------------------ <br />-- ----------------------- --------------------- ------------------------------ <br />Indicate the responsible party to be billed for additional EHD staff dme expended beyond permit payment <br />ooverage per tank. If the party designated below is different than the permit applicant, e.g. property <br />*wner, the party must acknowledge this responsibility for the billing by signature and date below. <br />,-4ame ress <br />Cz_tLja_� 6 -Add <br />Phone# 17Z-7 <br />C a, <br />fit <br /># <br />