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ZWIRONNENTAL HEALTH DIVISION • <br /> • f�F! <br /> • APPLICATION FOR UNDERGROOl R RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS PERMIT =%FIRES 90 DAYS FROM THE APPROVAL DATE.__ 000 NOT WRITE IN ANY SHADED AREAS' '-NOiCa'T PE M:- '^--- 3ELOW: �3q <br /> 1 <br /> _TANK RETROFIT 7/ PIPING REPAIR <br /> EPA SITE % <br /> I PROSECT CONTACT 6 TELEPHONE Qeirnatin - - <br /> PHONE <br /> F I AGILITY NAME Q�• `� I SfPf1fJ/� 4 n <br /> A <br /> C I ADDRESS '171 4414 ife r <br /> L >t+C, Sire <br /> L CROSS STREET � <br /> I r <br /> T I OWNER/OPERATOR <br /> Y I TacSlC I PN' % : �l419 <br /> �( I - a� <br /> C I CONTRACTOR NAME I PHONE % <br /> ° gJ3S I CA LZC % 7J -7 CLASS d Z <br /> N I CONTRACTOR ADDRESS utj <br /> T WOEE.COMP.% DQg'17�-10 <br /> R I BSVRER („ i � ll'A <br /> A F- <br /> C OTHER INFORMATION <br /> T PHONE % I <br /> of <br /> R 2RONE % I <br /> I <br /> IIIIIIIIIITANK IIDI%111111111111 TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE QST INSTALLED <br /> 39- Sns4 -o( 1 I I I <br /> T I 39- 1 <br /> 1 <br /> A I 39- <br /> N I 39- I j I <br /> K I 39- i <br /> 1 39- 1 I <br /> 139- 1 <br /> -HIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIfI11II1111I1I1IIIlII1I1IIIIIIIIIIIIIIIl11I1II11I11I11II11II11111I1I1I1I1I111II11 <br /> L 1 APPROVED �V APPROVED WITH CONDITIONS) DISAPPROVED <br /> A I (SES ATTACHKENT WITH CONDITI-ONS) <br /> N I DATE 25 <br /> PLAN REVIEWERS NAME _G 9 <br /> -HIIIIIIIIIIIIIIIIIIIIIIIIII 11 IIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIlIl1IlII11IlII1111111f1171111II111I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAM MACU'N COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS OF <br /> SANeOAGUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSID AGENT'S SIGNOT NATURE Ate[-IYTo�AS�`ITHE SUCH <br /> O�I� -PIAS :OT 3ECCMEFY T `Y <br /> IN <br /> _ PERFORMANCE CF "",{E WORK FOR WHICH THIS PERMIT IS ISSUED, L SHALL <br /> SUBSECT TO WORK,A'S COMPENSATION :.AWS OF CALIFORNIA-" CONTRACTOR'S HIRING OR SUSCS� L PPLO I?�ERSONS SSHSECT�O WOR'GR'SWING:i <br /> "I CERTIFY THAT IN :HE PERFORMANCE OF NG <br /> TS-- WORK FOR WHICH THIS PERMIT IS iSS'cD, <br /> COMPENSATION LAWS OF CALIFORNIA." o <br /> Qx� <br /> T:TLE -e DATE. <br /> APPLICANT'S SIGNATURE: L� <br /> ILLING INFORMATION: <br /> ndicate the responsible party to be billed for additional PHS-EHD staff time <br /> xpended beyond permit payment coverage per tank. If the party designated <br /> elow is different than the permit applicant, e .g. property owner, the party <br /> ust acknowledge this responsibility for the billing by signature and date <br /> elow. nn <br /> ame18 <br /> m�cX��eJ11=- <br /> eW addnnress j& F�7u�we (f4S6c '710&-N hone number '710&- 2 Z <br /> ignature C 11 aX- <br /> 00KPj !&1,4 I PPPftVA-L. C' KZ M 01.1 AL. UPO),J tffGl el�:,rI- C>p=- <br /> CL,05v2G 'PLAt.1 <br /> H 23-0038�A„� i 14 <br /> L48 j+rS lr � NGc f< <br /> iVRYZ, <br /> l All �I Pwl�r MUST- YVI� 2F-qu 112-emEWVS c~r L4 i 13 <br /> �uJ►nr v- Rasmus-� wU1 ks A�� <br /> Cf- R- z�36(0 +9r►Nua ( lltie <br /> TNE� 'T�5T5 <br /> wrn&L- sHu-ro;rFwi-iw 5&-r xr 90Z 4am k VC)LU M E- <br /> u�eve.lu(- i <br />