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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDEOG TANK RETROFIT, TANK LINING, OR PIPING 0R PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FRC.M THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE 8^c LCV: <br /> ,�7ANK REPAIR/RETROFIT __TANK IIHING PIPING REPAIR <br /> EPA SITE I PROJECT CONTACT L TELEPHONE 9 � <br /> F FACILITY NAME <br /> A PHONE 9 <br /> C ADDRESS ' S (� <br /> ! 1 <br /> L CROSS STREET <br /> I <br /> T ` CWNER/CPERATC7� fl I PHONE T <br /> I <br /> Y /� <br /> �/ Z <br /> C I CONTRACTOR NAME /` I PHONE ,X / - <br /> O J t. / <br /> V CONTRACTOR ADDRESS 3 <br /> CA LIC l CLAS <br /> Z INSURER p <br /> 1 -xmz <br /> A WtRK.C:.MP.;. <br /> C OTHER INFORMATION tJ <br /> IT <br /> O <br /> R PHONE R <br /> PHONE 9 <br /> `. I111111(I11(111I111(I11111(till �. <br /> TANK CO 1 TANK SIZE CHEMICALS STCR£O CURRENTLY/PREVICUSLY I OAic UST INSTALLED <br /> 39- <br /> A 39- <br /> V 39- <br /> I <br /> 1111111IFFIll flillitilITFFFFFITFFTITTFFFFFFTTFFFITI it IIIIIIIIIIIHIIIIII <br /> 7APPR APPROVED W17H CCNDIT:CN(S) DISAPPROVED <br /> ACHMENT WITH CCNDITICHS) `z6`. !J PLAN RE'/IE'1ERS NAME <br /> DATE <br /> �ll(IIIIlII11111iI11I111 I11 11111 11 111111111111 111111111111111111IfJlllti 11111111111III1ifli11111111fi11 Illl111111f111 <br /> APP !CANT MUST PERF-CRM ALL -tRK IN AC;ZCANC: WITH SAN :CACUIN COUNTY CROINANC►S, STATE LAWS, AND RULES AND R£_ULA7:CNS OF t <br /> SAN ICACUIN CCUNTY PUSL!C HEALTH SERVICES. C'.'NER OR L:C_NScO AGENT'S SIGNATURE C3RTIF/ES THE FCLL_'ING: ": - T:FY THAT IN <br /> -Hc Pcgc.CRMANCE OF 73E .CRK FCR -'HICH THIS PERMIT :S ISSUE] I SHALL NOT EMPLOY ANY PERSCH IV SUCH A MANNER AS�TO BECOME <br /> Sug.._C7 ;C :CR_=R'S C=MPSNSA7:CN '-,;:-S JF CALIFCRNI.1." _^,NTRAC-CR'S HIR:NG CR SL'G=4TRAC7 NG S GAA UR£ C R?:".'cC THE F•.-.LL:'IYG:! <br /> '^_- THAT iN P_R.CRMANCE^OF 7HE :QRK rCR :CHIC:i THISPERMIT <br /> C 1PE:IS i;.ON L.;US CF ,AL:tiRN:�." :S ISSUED, I SHALL EMPL^Y PERSONS Si6_EC7 ;C :CRK�R'S <br /> APDL:CAN7'S SIGNATURE: a <br /> LE c 811 O p <br /> 9 S <br /> iNF:RMA7;CN: <br /> .,ticaca -ne -esaensib(e zar-y -a _e hiUe- °or acdit;eraL P4S-=:-O s:a-"' _ae expenc!ed reycnc persic caymen; =cverage oer _ank. it Ve <br /> .zr:y cesiq^a:r ce?ou is c;zzarenc -nan ,-e :e-:i� acpt;cant, a .r^^ <br /> ;. er^/ tuner, :fie ar^/ .nL ac .es+Lge is rospers;oiL;;y cr <br /> .'e .iitirtc --y signac::re arc case teLcu. -• ' <br /> `!ailing Address �� l <br /> 'ay ?hone H�.�tC ^ �� <br /> S i qra cure <br /> n <br /> vi <br /> 1 <br />