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71 <br /> E <br /> SA COUNTY HEALTH SERVICES AGBft <br /> E F1RON1(ENTAL HEALTH SERVICE <br /> 701 Ocean Street,Room 312, Santa Cruz,CA'95060(831)454-2022 <br /> APPLICATION FOR PERMIT TO MODIFY A HAZARDOUS MATERIALS FACILITY <br /> [PERMIT EXPIRES 6 MONTHS,FROM DATE OF APPROVAL] <br /> ATTACHT;WO COPIES;OF PLANS ASSOCIATED WITH PROPOSED MODIFICATION <br /> INCLUDE SPECIFICATION SHEETS.FR(3M MANUFACTURER WHERE'APPLICABLE <br /> 12/% O t23PM, 0P, 1900 €002 <br /> PLO521 $2'36.,00 , <br /> MIT NUMBER: E PAID 2 QDDATE: Z y D CHECKszm Cit. <br /> �E / <br /> (] <br /> CASH REESTER VALIDATION <br /> ation ` hl� ��-� — <br /> icility Mame-, ?0 Ct 7N\(' APN <br /> Iner/Operator P }P\C, IK L Telephone q2��623 SZ66 <br /> r perty Owner �� ��- Q�1-�- _ Telephone Z S $23 <br /> ttractor- <br /> ress <br /> _ 3q09 PPRk- 90P)D i leeo+GIC_ <br /> o- 0 qqj <br /> teense Number ��� -� .Telephone � C� <br /> nerBuilder Declaration submitted: [ ] Yes [ ] No [)C] Not applicable <br /> DIFICATION BEING PROPOSED: <br /> all equipment proposed attach manufacturers specifications sheets, and installation and maintenance instructions. <br /> materials of construction must be compatible with materials stored_ <br /> Monitoring Device/System ❑ Overfill/Spill ❑ Secondary Containment Structure <br /> (Attach Monitoring Plan) Protection (Attach capacity talc sheets and <br /> identify materials of construction) <br /> Repiping ❑ Aboveground Tank Other <br /> � . . <br /> r. <br /> TITLE DATE <br /> #4vIKwt EKAL FOR OFFICE USE ONLY <br /> HEALTH DEPT ATE: '� d EXPIRAT 04/02 12:27%PM ON DATE: � o <br /> �BA4900 0002 DATE: <br /> \\ <br /> P1_O-521 $27Q.00 DATE: <br /> LECK $2:+3.0E E-EHS YELLOW-OWNER PINK-FISCAL <br />