Laserfiche WebLink
APPLICATION FOR UMOERGRC.:NO TANK RETROFIT, TANK, LINING, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FRC.M THE OVAL DATE. DO NOT WRITE IN ANY SHADED ARE0INOICATE PERMIT TYPE BELCH: <br />_TANK REPAIR/RETROFIT _TANK LINING _ PIPING REPAIR <br />EPA SITE �. I PROJECT CONTACT 3 TEELEPHCME <br />FACILITY NAME.cz� xfl� _ & D � <br />A .L <br />C ADDRESS S I!L— <br />I ��77 <br />L CRCSS STREET S <br />I <br />i OWNER/OPERATOR A <br />Y 4-- - w <br />C I CONTRACTCR NAME <br />0 <br />I NI CONTRACTCR ADDRESS <br />R i iNSURER r1 e <br />C I OTHER INFCRMATICN <br />T +I <br />0 <br />i R <br />A <br />N <br />I K <br />Itlllllilllliltl11II11(IlIIIII <br />//r)TANK io T _ <br />39- <br />39- <br />39- <br />39- <br />PHONE +S�O- <br />PHONE <br />.2o - 9os <br />PHONE = O — 337 <br />Cat . <br />CA L I c = 6�0 00741C CLASS <br />4 3 q / #r <br />, 00 93 c <br />PHONE <br />PHONE <br />T <br />TANK SIZE I C3E'1I <br />1 <br />i <br />x4= ROVED APPROVED WITITICN(S) <br />SEE AiiAG{MENT WNo IT TONS) <br />3LAN RE'/? E'JERS NAME DATE <br />1i1111111II11111111Il1111lI 11 !111!1 /L49AIN <br />A?EL!C:NT MUST ?ERFCRH ALL WORK IH AC=ROANC: WITH SANC..t13i' OROINANC-S, STATE '�3SJS, ANO RUL=S ANO REiJLAi:CNS CF <br />SAN .CACUIN COUNTY PUBLIC HEALTH SERVIC-S. =74ER OR LGENT'S S:GNATURE C_RTIFIEES THE FCLLCJING: "! C'IRT:%' THAT IN <br />THE PERFORMANCE OF THE '-'CRK FOR WHICH THIS PERMIT IS ISHALL NOT EMPLCY ANY ?E.ZSCN !N SUCH A :4ANNER AS TO 3E -CME <br />SL'B.:ECT TC 'JCRKER'S :.".MPENSATICN LAWS OF CAL!FCRNIA."CR'S HIRING OR S::BC..NTRAC":NG SIGNATURE =-RTlFI=S THE FOLLOWING: <br />CERT: 7HAT IN THE PERFCRMANC- CF THE '.:CRTC FCR WHIERMIT IS ISSUED, i SHALL EMPLOY PERSONS Sua--r TO WCRKER'S <br />Cr.MPENSATiCU 'LAWS OF :AL:FCRNIA." <br />YIPREVICISLY i DATE UST INSTALL=-:) <br />I <br />DISAPPROVES <br />I <br />i <br />I <br />APPL:CANT'S SiaNATURE: <br />3!L -':NG INFORMATION: <br />TI TL= P�4 y A 1 DATE 1116 <br />!rdicace :he resconsible Party :o be billed foaddirionat PHS -SHO staff :ime excs-med beyond permit payment coverage per :ank. If the <br />Par:y aesignaced beiow is different than :he rmit applicant, e.g. property owner, :he par./ asst ackmowteage :his resporsibiti:y for <br />:ne ciil-ing cy signature and cats below. <br />.Name / <br />'!ailing Address <br />Oay ?hone Number ( ) <br />Signature <br />_H —7-3038 <br />Z n,���-tom' ✓t �� 3��'-�-dr� <br />4 <br />