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.: -- --- <br /> l APPLICATIDN 3CR MA ERGROUp ^H.FR R£LOFIT, OR PIPING REPAIR PERMIT <br /> TIS ?ER 171 EY?:FLS 90 DAYS FRC- h APPROVE DATT_. DO NOT wR IN k: SRADED —PE 9Elfiw: <br /> _TANK R-:_OFIT PIPING REPAIR <br /> IYA SZTE 3 YR Cr CONTACT l TEL.EPNC�Z a i �.l©'j ` C ©A. N . PRDNE / 20 l <br /> Locic�o (- \ CC4 <br /> I <br /> CROSS STREET 1 <br /> I <br /> T I OWNER/OPERA a'-OR��, 1 YHDNE . i <br /> CONTRACTOR NAME 1E }t 1 V C.o n}r /ten— 3 <br /> T1 CONTRACTDA : ORESS /l l•2 T` ` '` 1 G LIC 3 �I OV\1 I CLASS t 'T'JI <br /> R ! ZNSORER 4]� L�U J�J �V`J Vb I �1 V.�D�.3 OV�- bo�761 C•j• <br /> A GJ G <br /> c I DD{£R xNInR.arloN I j <br /> r <br /> o I ! PRONE � t <br /> R , <br /> Ianaarta3 rtlaa allnaala••raiz a• I PRONE 3 1 <br /> �1ll3l•!arra lal Ia•aria lltll l' , <br /> TA.vK IDS T+\=. SIZE CFIEISICACS STORID CURR£NILT/PREVIOUSLY DATE UST TM 1 <br /> 19- 1 ( O 1 <br /> T 1 T9- <br /> .1 1 T9- <br /> I 39- <br /> �11IUtIlitHilllFllllilil111(iltiHlltlllltilllf�lllllllltitllllllllllFll)[llllFllll[IIIIIIFlifi11111111I111Fllllllllil111111� <br /> L 1 AeeRwF.DAPPROVED WITR carol-_za+Is7 _ DISAPPRowED t <br /> g, Trncug�.r UMmxD-xoxsl -02 <br /> 1 <br /> n 1 !l/ AMIR�7.L- <br /> -i1I1111llllili Isftl Illlllllllilliltil_ I1II111t1[titlillllll[llllllllflllll11i11lililllltllll111111tH[llilllltlillitlillllltii <br /> APh.ICpNI MUf DAZE <br /> ?ERfORH ALL YORX IN ACCCRDAVC= .:TI SAN JOAQUIN COOT! 02JSTATE URS, ?NJ RW.FS .lMl IA1IfATIONS OF j <br /> SA.Y JOAQUIN CORRNTY ?UHLIC Na Sr VICES. OR LICENSED AG 'S S� CsCIZFIES THE FOL n,; 'Z C`�l2IFY i T :N j <br /> 'S. pEFFOROfANC' OF THE RORK FOR 'N M THIS ? 4ZT ZS ISSUED. x SEAQ. NCE rZI Y ANY PSRSON IN S A YAMMER AS TO BEC <br /> SUStECY TO WOR. -S COKt SATIOS LAWS OF CA[.,..ORMA CONTRACIUR'S HI]_vG OR SONCONIRACZIWG SIGNATOR£ C xFILES I E FOLTOWING-t <br /> • =XFY TSAT IN THE PERFORM CE OF TRE WGRa FOR WRIOt TRIS PEWT IS SSOED, I SHALL EMPLOY PERSONS SUBJECT TO woftO •S 1 <br /> C'OM IATZON :.ANS OF CAI.:FORNZA.' i <br /> A?PLICu+r.S SIGNATURE- `1LL4 TME �F CV\ C DASE j1- _Oz <br /> BELLING INFORMATION- <br /> Indicate the responsible party to be billed for additional PHs-FHD staff time expended beyond <br /> ,exmit payment coverage per tank_ If the party designated below is different than the permit <br /> applicant, e_9_ property owner, tae Darty must acknowledge this responsibility for the billing <br /> by <br /> signature and date <br /> date below_ r� I <br /> Name_L '( T'Q- 1 V ad`dreeses,2W�53S gWanphme number `4 j' 0�i 7 <br /> Signature. Q(`Q.R.. <br /> c.x 23-0038 �IDIf76W1 vcr `IV av ✓a Ie- ave <br /> lj.ns tl Im of- +Ke, Revs "K cl&e<1vr . _. <br /> 2. A-IIDW 146' }' ntr n041'"C -6y- all Cnspeamn uwoivr S <br /> 3 . 5mq fctul i ns P e c-h yr I 5c ,utA v j,l 31 200 3 <br /> i <br />