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12/09/98 16:32 NO.078 1?O2 <br /> ' • "'Vin............. ncrL .� Jl(lilGN <br /> • APPLICATION FOR UNOERG20UND _AK RETROFIT, TANK LINING. OR PIPING REPAIR PERK_ <br /> THIS PERMIT EXPIRES 40 DAYS FRCM THE APPROVAL DATE. 00 NOT 6111TE IN ANT SHADED AREAS. INDICATE PERMIT TYPE BELOW: _I / <br /> TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE 3 I PROJECT C.-INTACT S TELEpHCNE A r+'C <br /> CF FACILITY NAME aMCNE <br /> C ADDRESS <br /> I <br /> L CROSS STREZ7 <br /> I <br /> TOWNER/OPERATOR PHCNE Y \ {� <br /> CI MTR1ACTCR NAME K T M+ ASN I PHONE <br /> N CONTRACTOR ADDRESS ..` �VqL .� I CA LIC i rrss <br /> INSURER �\1 I LGRY.C:MP.1 L'k ck" <br /> { OTHEZ INFCi1MATi0N L`C,1�'CCt�LtiCQv <br /> T <br /> CC�� +-'Aco <br /> PHONE i <br /> R <br /> fPHONE 'J <br /> t11i111 11111111111111111111111 <br /> TANK TO 9 TANK STZ; CKEMICALS STGREO CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> j4- L I�crO� �n�.Se�e�t U+.AICt'o..�n <br /> T 34- 2. �1.....-L� •• �� <br /> 39- <br /> I z 39- <br /> 39- 1 <br /> 1111 <br /> P <br /> L ZAeVQ:VED AP tTVED WIT NDtTILN(57DTSAPDRGVEDA EE 11W WI NOITIONS <br /> N PLAN REVIEWERS 4AME C DATE / U <br /> � 111111111111lllltllt 1 it i 11/111 !I 1!i!1!ltiliiili i <br /> iAPPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JGACUIR =)ITT ORDINANCES, STATE LAWS, AND RULES ANO REGULATIONS OF <br /> SAN 'CAOUIN CZVNTT PUBL:C HEALTH SERVIC=2. OWNER OR LICENSED A4ENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT 19 <br /> THE PE7FCRMANCZ OF THE WORK FOR WHICH THIS PERMIT IS issuED, I SHALL NOT EMPLOY ANY PERSCN IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S CCKPc ON LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> ,I CEZTIFT THAT IN THE 7 RFOR C_ OF THE WORT' I-+I S PERMIT IS ISSUED, I SHALL EMPLOY PERSCNS SUSJ£ZT TO LCRKE+T'S <br /> COMPENSATION LAWS Of GLI ORNIA. <br /> � <br /> AGO t'Q 1�C \ aG�et �— <br /> APPLICANT'S SIGNATURE: TITLE DATE \�-�$�I1� <br /> 3ILLING INFORMATION: <br /> Indicate the responsibta party to be bitted for addltiomi PNS-EHD statf time etperded beyord permit psym mt coverage per tank. If the <br /> party aesisnated beton is diiferent than the permit applicant, e.g. property otmer, the party must acknowledge this responsibility for .. <br /> the bitting by signature and date below. <br /> H°me--- P-2C10 3r. <br /> Meiling address �� •��{r <br />