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�--tw <br /> - NVIRONMENTAL HEALTH DIVISION <br /> .We <br /> APPLICATION FOR UNDERGROUND :ASK RETROFIT, OR PIPING REPAIR PERM. <br /> THIS PERMIT EXPIRES 90 DAYS cECb XTHEAPPROVAL ]ATE. DO NOT WRITfi IN ANY SHADED AREAS. INDI= PERMIT TYPE BELOW: <br /> TANK RETROFIT' PIPING REPAIR <br /> :PA SITE k PROJECT CONTAT. 4 TELEPHONE % <br /> e^ 7ACILITY NAME TOS D PHONE '(za 5J 0Y3 <br /> A r <br /> C I ADDRESS & -/10- CA M br/RSCS A.fYI eieaq <br /> I - <br /> L I ORoss STREET <br /> T I OWNER/OPERATOR I PHONE k <br /> Y I Tosca 1 ! ao9 Qys-SoS <br /> C CONTRACTOR NAME �F/I.ITEAP'S'OA/ �N'TVIJCT/U/3/ ?HONE IGO0 9V3-50S�' <br /> o <br /> N :ONTRACTOR ADDRESS <br /> T <br /> cA '-:C f"AEE A-ao$OEtc/honf <br /> R WORK-COMP. <br /> 'Qco nJ %1031yf <br /> T-'19'?� <br /> C I OTHER INFORMATION <br /> T I <br /> OPHONE k I <br /> I <br /> R <br /> I ?HONG % I <br /> TANK :D k TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE VST iNSTALL30 <br /> T 1 39- I I <br /> A 1 39- I <br /> N 1 39- <br /> 39- <br /> 39- <br /> 39- <br /> 211111111111111, <br /> 9-39-39-39-11111111111111111111F)1)�111)))il)1)))111i)))ill)�)111)1)11))1)X11)1)1�1)1111))1))1))�))11))1)ill)11)ll <br /> L I APPROVED )CAPPROVED WITH XONDITION ISI DISAPPROVED 1 <br /> A 1 CONDIT:ONS) <br /> N 1 PLAN REVIEWERS NAME (523 DATE Ila- <br /> �I111111111111111111111 111111111 I 11 I 11 1111 1 1111 11111111111111 11)11111111111I11111111111111111111111111111 it I� <br /> APPLICANT MUST PERFORM ALL WORK :.N AC.^C. CE WI_?I SAN ,;OAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN :CAQULN COUNTY ?URL:C HEALTH SERVICES. OWNER OR LIC"-LASED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CST-:1 "EAT IN <br /> - PERFORMANCE OF THE WORK ?CR WHICH =5 ?ERMI'. iS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A M WEA AS ro 3EGME <br /> s 3 LC-. TO WORKER'S COMPENSATION :,AWS OF CAL:FORNtA.- CONTRACTOR-5 SIRIMG OR SUHCONTPAL ING SIGMA^'RE ^-.RTIFIES THE FOL:OWING:I <br /> ^T -E :FY THAT :N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS :SSUED. I SHALL EMPLCY PERSONS SUB=. T, WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.- <br /> APPL:CANT'S SIGNATURE: :&QL� Q�O��J TME DAYS <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond <br /> permit payment coverage per tank. If the party designated below is different than the permit <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br /> by signature and date below. <br /> /P <br /> Name A&yoPJ Cavi address ;Iog-a Fogammit hone number CZd� 9Y3-SUSSI <br /> Signature <br /> �,OtJU1T1pN 5 : <br /> t�Iy localre^ �d Lte✓�t .. ,. nn -- ^ I 1 �� <br /> EH 23-0038 2- Call ` 8 kovvS 1✓) aoly ce 4D sckgcL K1C. �' t�po )yIfwvt S . <br /> 3. A 41 eGi biA pmcAt �n5l zdl lcd rv>U.!�A- be uL i(*:q- <br /> �. Al wfal im Omfacf- )vio backfill mafrvL0J mu-sfbe corroscov, <br /> 5. 4U dtk pt fe. I s reVyV/' d -rD bC Cs-k* ,-hU L k_ WW 1o'e, <br />