|
r �
<br /> 00f ACl/LVOD U7;U1 ,fIl7491j•:'ml]J, c-'W ^�`- "•
<br /> SAN JO-AWN COUNTY
<br /> ENVIRONMENTAL,HEALTH DEPARTMENT
<br /> OPt 6 WCNIR AVIii,VC VLOnn
<br /> 9TOWTON,CA 141oa
<br /> ApPLI:JTION►Dri UNCCRrS1WU}iD YRw,RT ti F!'.OA FfWNG cirph�P4FVA t
<br /> YW3 PERMIT EXPIRJS it!)AY6 FROM THEAPPRWA4 0A1 E, 00 001 WAV,N AW t'61pEU/AAW.irgWCATE!1tfRK"TYPE DELOW:
<br /> .........
<br /> �7ANHR1:TR0rrT PW!.V/3RPPA1ftAATPO!'IY,- UOik^h
<br /> r .. ,. �I9.......................CONTAINMENT CPAIRI cM.TkVF!T
<br /> I I,¢RA:FIT¢ I •I P1a1keT CGfiTACT A•TCLIRrONTf V ••
<br /> i ► ~;BUJ; -- �.............. . . ... .._.
<br /> I >GG11k0Y� / ,. ,J ••A_ ,. ......
<br /> z : cxoai•arA':fY �• ....-----•• ......
<br /> Y tl+t JF� .i.Ir;�[ 1 I YHONT r ` ' �1 `/� �(
<br /> I C I•CONt1LtCY0A R1AYi Y-'* r _ +•••••• �`:` `W'•
<br /> I 0
<br /> ..............
<br /> .............................
<br /> : PHON<,1`"k.(.: 'Si', �
<br /> ' r COatlUlt'Yp) AOCAICO /�/ ������'�,�•� '^" ---
<br /> I Y i-.. _• ....,... �1.:.£:/yr).b. �+rn/�Yf_=.�:ni.s'.':•J.:.._...�A...�r_ ��_�����_ I Cu1¢Di'^ �
<br /> I
<br /> ViArik
<br /> A ` I /j . .. .J., ._ r LYcr:S15•.•7.F.1. J,�s-;
<br /> C otNet•rfrrot,uTror •.. ._..--- ........... .. .... .... ,
<br /> T ............................ .... ....... ....... ............. .. _....,...,.•,.._._-__ -I
<br /> ...........---.
<br /> 7HONC 1
<br /> ----------------
<br /> -11...,.1,,,,:11;III:II111t;IIIlI•.............. .......••..... .. ....
<br /> II �f• �tf�.-��.i� f/` p -_�IA•.V_-
<br /> 7AMx ; 41 919I _ICAY LTd VSSN[T7LL➢b, `•t
<br /> K 1 I7• wl , I
<br /> • iilll „ I ;II I 1 ,.I i ( 1 11 CI I, IT „I��;jl�T�1T`IIiT T7,;111iliitl {.iI; T;
<br /> ! '• I � ArP1lovRt, A1RRpvtrt wnK CarDTTtONItI u[wtrYRovap
<br /> A TyJi� ATSALRKVft WTH CON*1nWAI —
<br /> n }LAN 11tvITSICU NAME OAT➢
<br /> •-• ;I„Illllllllll!{1111111 !.I.,II (IIJ I II II ! f,
<br /> I li ,I ;I•II , ,.lilll 1111• ;777777,1,
<br /> ;I
<br /> 00161CANt MVST /titfogn Ap.VopX zr ACCO C6 YT1r IAM JOAay111 COVNTC 0RbXYA�tCil, #TATX IMS, AND AVLl1 AIJD KrCTIATI and OF
<br /> 5AM J WV1H coy"Y, 11tV1AVANtv1TAL Atl►{TM �AxtMMT. owtA aR trcrNgIp Aglaq 41ONAMt CRATTI443 ;ht rdtt.ONINO, ''7 CYSrtTY
<br /> tfiAY tv tNa 1111111116A of GM 7418 Rmwrp If at9Ute, 1 cmw- >•or tt'nor ANY rrivoo 111 1VC1! A HANNY➢.AN To
<br /> I Awepu !WJ¢CT 10 r01 ( t d�NJA t>t. LA.• CC iT�Mt7 GR�� P!At V CK tV1CQF^ib4LTih� dlixNrvra :1N;X►I➢. TNT
<br /> POLWVINd, •T C¢RYi 1t 1t Il! IQPYlA ti 0► Satl1 wy101"13 ILARTT td 1erurV, t'tNALL DDI- RC
<br /> NOIUfEA'fl CON11rtiRTI rt 11OAMtA; ` y ,tacN3 0(weCT to
<br /> AD1L7ClNT't YkC11ATU , TTYLI'� J/•/��St,YL,. 7�v�
<br /> • . ...................... ..........•...... .........__._._ ....... .......................,.............
<br /> ........ ...___
<br /> BILLING INFORMATION:
<br /> Indicate the responsible party to be billed for additional IHD staff time expanded beyond permit payment
<br /> coverage per tank, If Miry designated below Is.different than the permit applicant:, e.g, ,property
<br /> owner, the ledge this responsibility for the billing by signature and date below.
<br /> Name Addre95 `f�Yr(� -�'�l�}z Phone Zz
<br /> Signature lL ~t St t,�lA
<br /> EH230038 -- - ---
<br /> (revised 1131/02)
<br />
|