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'J:bapm FROM P 3 <br /> ... <br /> ENVIRONMENTAL NEALTA DIVSSION 1.01 <br /> "APPLICATTON FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERNFT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NO, WRIT, IN ANY SHADED MEAS. INDICATE PB➢MIT TYPE BELOW_ <br /> Mani <br /> TANK AHiWG►S nI➢ia0 REPAIR / <br /> I EPA SITE k / �� � /�I PA0`3EC_T CONT/ACT 6 TELE➢HONE k (e-.r M�� Dec, [q S-) $^-Z--FevzI <br /> F I PACILITY NAME C/P�C�V Y-G Y� �'(�O IXµ�C� `OM �[T�_�• I PHONE k l��0�� 836 <br /> 3 -I Gt¢zL <br /> A <br /> C I AOORE.SS <br /> I <br /> L ; <br /> I moss srksEr <br /> I I <br /> Y i OWNEPER <br /> R/OA'[UR - 1 Prr7C.ITj �M i PMOdE k <br /> /V�/^,.,..-j—VT` �/� ��Fr`` T �92s) 8�2-9ooZ I <br /> CONTRACTOR NAME�aCro.,..J. Aa u+eMtr`t Aatnlg"- MCC 6.2 lhc- PHONE k (216) U-5— 27/6 <br /> TI COWr2ACrOR ADDRESS 25.33 (p➢lni� DiQI Uf 7gG_6 . CA LIC k Jr-OG-3 [ ! I C'[JISSA, C6t� p¢�I 'rl�f�l�'�T <br /> A I INSURER 0011 ``1 `1!Q( Gh9 4q,f,..�K i WORK. a1164o09 <br /> A r 1/'� `l C <br /> C I OTSEA tNFORNATION I I <br /> T <br /> 0 1 I PHONE A 1 <br /> I PHONE k <br /> TANK <br /> illtllllllllllllllllllll <br /> TANK SD • 1 TANK SIZE CNENZCALS 519AED OURAFMLY/P sLY I HATE I= zxr.3w.tED <br /> 1 I <br /> 1 39- ) 1- 2.=e� I ���WpS�' �, <br /> � ..-la.a= ! 14616 I <br /> T 139- Z 1 �y Doo I tti'dl?r LP.A I--CR46 I <br /> Al 39- 3 I l$Pl�00 I �A^r 1,.. •� I 1946 I <br /> N 1 39- <br /> K I 39- t I I <br /> 1 39- 1 I I <br /> 1 39- I I 1 I <br /> �Illitlliilllfitltllllilll111 IIIIIIIIIIIl1lIIIIIIIIIIIItIt111It11i111111111111111111Illllllllltlllllllllll111111111111i1111111 <br /> L 1 - APPR APPROVED WITH CONDITION(S) DISAPPROVED <br /> N2TR CONDITIONS) {t 3(J <br /> NJ PLAN R IENERS NAME DATE <br /> —HIIIIIIIIillllllllllllllli f 111 11 (IIIIIII1111111111111111111it1f11111111111t1i111111ItI11111ti1111111111111111111i11111 <br /> APpLICANC NUST PERFORM ACI. WORK IN ACCTIRDANCE NITR SAN JOAQUIN COUNTY ORDINANCES. SCATS UN , AND RUL- AND REGULATIONS OF <br /> SAN SOAOOIN COONTY PUBLIC IIFA . SERVICES- OWNER OR LICENSED AGSNT'S SIGNATORE CERTIFIES TRE POIJDWING: •I CERTIFY TezAT 2N I <br /> In PERFORMANCE OF THE WORK POA WNIO THIS PEAMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN SUCK A NANMER AS TO EECCME <br /> SZIEJECr TO WDRKM.S COi@ENSATION '-AWS OF CALIFORNIA.• CONFRACTOR'S HIRING OR SUBCONTRACT=NG SIGNAMIkE CSRITFI3 THE PDLLONING:1 <br /> 'I GRTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WRICA THIS PERMIT is ISSUED. I SRAI.t. EMPLOY PERSONS SUEJECr T, JORKER'S I <br /> COHPEN.".ATION LAWS OF CALIFORNIA.• I <br /> APPLLCANT'S SIGNAITIRE: TITLE O II/IO DAT= I <br /> ILLING INFORMATION: <br /> ndicate the responsible party to be billed for additional PHS-EHO staff time <br /> xpended beyond permit payment coverage per tank. If the party designated <br /> elow is different than the permit applicant, e.g. property owner, the party <br /> ust acknowledge this responsibility for the billing by signature and date <br /> elow. <br /> ame 'JjjC add fess (( 7 3UPhone hone number ('707) 765- a'!b <br /> ignature <br /> H 23-0038 (/f <br /> 14C, <br /> j?L ll?C� a rira <br /> anv l� r <br />