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12/21/2001 09:25 2094693433 FIFTH F`L-00P PAGE 07 <br />F <br />A <br />I <br />L <br />I <br />f <br />T <br />SAN MAgUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDER.GR0UnD STOMr-� TANK INSTALLATION PERMIT <br />AMP:RMIEIMAYION FJfTRHWA=NTOI011 FLIWGWlEXT CALENOAR YEAR IF AALETTiR ISKS IS LSElIA1TO FNlp `-EHD R"pUE3TIHOETdI$HEXTEN8TOH THIRTYqHjl:H IT HAS ¢GAYS�EO <br />PRIOR TO THE El40 OF THE CALE90AR YEAR. A CUE 11MC, CAI=_ TE.Az EXTE931CX W HE 'RANTED BY P,.Is-EHD UpaH RECEIPT OF TRcs tET Ea. <br />00 NOT 41R1TE IN AMY SHADED AREAS. <br />EPA SITE Ap-ROIECT L�tTNJTAC�ij�ijI LEPHON: �T �7(� 1 ! �1 <br />FACI L I T Y NAME 'At pH0N6 �` <br />ADDRESS 3 I ITt�i <br />CROE8 Sffutr � � hex <br />PHONE d l _ <br />O.IRLR/GPERATOR 1 i��J '�_ <br />SONTRAC'IgR xAMEP�pG1i�1G C,l 7tLA <br />[;CJ17>+AAC70R /tipDIEESS �^�� r y <br />3.47A lJs UAETE CERTLF1i0 Y!5-_ _ N9, <br />FERE DISTRICT Z�. <br />50AR0 OF 9WALIZATIG11 # <br />IIIIIIIIIi�l�plfillllllill TANK SITE <br />II T 39- <br />A 39- <br />N 39- <br />K 39- <br />39• — <br />39 <br />1111 DI5AFFA-"V90 <br />P P APPACVID HS'.H CC'NOTTICN(S) <br />CS ATTACKMtKT NITN WM91T104S) DATE ` <br />A 111111 <br />N PLA% REVIEUEA4 � II <br />I 111111111111111 <br />APPLICANT MU3i PERFCM RTIFY <br />ALL UCIAK IM ACCORDANCE - SAN 9AGJIN <br />COUNTY OAOIHANCLS, STATE LAYS, ANO RULES AND (s[=f.(ILhTLOHS OF <br />SAX JCADUIM COUNTY PUlLIC HEALTH SERVICES, pyNGR GR LKCOGED ACUT'SNaTCEMPLOY ANTliATURE TPc"RSONIFIES T177 9JCH AHE IMANHERIASE10 IEC4HELT E FY I T µ <br />11S£ psRpcAKANCE OF THE LORX FOR WHICH THIS PfiRMIT I55L6Cr 1 <br />SULL SUIJECT TO WORM'$ COMPENEATIOK LAWS OF GALIF "IA." CONT RAE70Ar9 HIS IS OR SURCOIIALL FMPL SIGMATI,'RE su5j c:TFI T THE T9LLE7,i1H <br />"L CERTIFY THAT IN THE PERFORMANC9 Of THE WORK Fa+ WICK TMI9 PcaHIT IS )SSU?0, T STIALL EMDLOY PERSONS StJT31!•GT TO ypRKER'S <br />COMPENSATINI LALIS OF CALIFORNIA," <br />TIT Ll <br />DATE <br />AFPLICARTrS SIGRATURE: <br />iniM <br />Irdieetr the respom3ble party tG be blitad for mWl-1 m^ RItie eddts" T'ebllcl of jngby Wyl3ndureeaa hdatembelonN i`aiEerirr <br />poymcrlt. Tk party InUST "knoxled9e this respvnsi y <br />came fi 0 , . . A <br />} 44:�T CJ <br />PH0�:6 it <br />GA L[C CLASS <br />WRK.LCKP-tr <br />FtKAIT 11 <br />CHEN.ICALS Td Qi STOAFO <br />OPOS$D'INSTALLATION <br />Hailir5 Addf _ <br /><A 7 � <br />Rey phone N%xbor. <br />Tete <br />Sigmtore <br />IN 23 008 (liter 1IZ, % 1 t?S 1 Rcgrs ►ley 5, <br />4 <br />.d 0026 13CN3Sd-1 dH WdSO:zT T00a BZ 33C <br />