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ENVIRONMENTAL HEALTH DIVISION _. <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PER.MiT <br /> THIS PERMIT EXPIRES 90 DAYS FRG4 THE APPROVAL DATE_ DO NOT WRITE IN ANY SHADED <br /> AREAS, IHDlCATE PE34I7 TYPE BEL{ICI: <br /> EPA SITE T <br /> TANK REPAIR/RETROFIT `TANK LINING <br /> IPING REPAIR <br /> � <br /> l PROJECT CONTACT & TELEPHONE :gF FACILITY NAME <br /> A PHONE 9 <br /> C ADDRESS 4 �_ y <br /> d <br /> L CROSS STREET `r <br /> I <br /> T OWNER/OPERATOR <br /> PHONE 9 <br /> C CONTRACTOR NAME J ! <br /> O <br /> CONTRACTOR ADDRESS PHONE N <br /> T CA LIC I <br /> R INSURER J CLASS <br /> A I W0RK.CCMP.2 <br /> C OTHER INFORMATION <br /> T <br /> 3 <br /> 2 <br /> 1 PHONE 2 <br /> 11(((((1(!1((((1((111((((11((( PHONE 3 <br /> T UK39- x� <br /> 39- SIZE C IICALS STORED CIJRR T YJPRE•VT,CLI LY DATE UST <br /> INSTALLED <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 111 <br /> 9-3939- <br /> 39- <br /> 39- <br /> 111 <br /> APPROVED APPROVED WITH CONDITICNCS) <br /> Ti A NT WITH CCUDITIONSDISAPPROVED <br /> PLAN REVIEWERS NAME r ) ' <br /> (11(1(111(11111(((111 1(11 11I[11 11(111 I1 11(11(( 1101111111((1111111 1( 1111i111D TE <br /> ((1I11 <br /> PPLICANT MUST PERFORM ALL WORE; IN ACCQRDANC< WITH SAN JCAOUIk COUNT? CRD[NANLzS,SIGNATURE C 11 STATE LAWS, AND RUL;S11AND REIGUILAiON510F1111( <br /> 'AN -CACUIN G]UNTY ?tJSLIC HEALTH SERVlCyS. <br /> HE PERFORMANCE OF THE L-URK FOR WHIC9 THIS PERMIT IER SS ISSUED, IAGENTSHALLSNOT F�MPLOY ANTTPER"THE rpLLflWING: L CERTIFY THAT IN <br /> U6jECT TO WORKER'S CCMPEtIS ICH LAstS OF CALIFORNIA_" CONTRACTOR'S HIRING OR [N SUCH A MANNER AS TO SECOME <br /> I CERTIFY THAT IN THE PE. C NCE OF THE WORK FOR WHICH THIS Pr. SUBCONTRACTING SIGNATURE C,ZTIFIES THE FOLLOWING: <br /> C.-IPESSATION LAWS OF CAL ORN A 'EMIT fS ISSUED, I SHALL EMPLOY PE.RSCNS <br /> SUBJECT TO rJORY.ER'S <br /> r <br /> PPLICANT'S SIGNATURE: / / y / <br /> TIT ,C.l � 7E 1 <br /> :NG INFORMATION: <br /> 'ace the responsible party to be billed for additionat PHS-'ciD staff tune ex <br /> ' designated below <br /> cu is different than the ed <br /> permit applicant, e_g- property rnmere� �� Permit Payment covers e <br /> o i[[i ng ty Si a lure # per tank_ If the <br /> date bet party �t acknowledge this responsibility for <br /> n5 Address _ <br /> � r <br /> lone N r G) _ <br />:care <br />