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0 <br />71 <br />304 East Weber Avenue, Third Floor, St n, California 95282 <br />Telephone: (209) 468-3420 Fax: (209) 46&3433 <br />THIS PERMri EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW <br />UTANK RETRORT UPIPING REPMURETRORT I h rru' RFParR <br />F <br />A <br />I EPA Sile # <br />Project tardast 8 Teledyne # Car r r - - <br />C <br />Facility Name <br />'5 elPhone <br /># <br />L <br />Address <br />Ln S ine-kftna,C ,=2-6 <br />I <br />T <br />Cross Street <br />Y <br />ownerloperator A, <br />�, �; <br />Phone # q �%J 9 <br />QContractor <br />Name <br />n a <br />®Y � ry �j c . <br />Phone # <br />T <br />Contractor Address <br />+ <br />CA Lie # ' (� C} ! Class/9, /!� d j� <br />Atr6Ur@r <br />® <br />Work Comp# (�®Q.`a-� i -7-7806 <br />T <br />ICC Technician's Number S^ S- '7C�g—LL-F <br />Expiration Date C3 j <br />R <br />ICC Installer's <br />ate <br />Tank ID # <br />Tank Size <br />Chemicals Stored gate UST Installed <br />Curtenshr . <br />T <br />A <br />k <br />K <br />P <br />LJAppmved <br />ATApproved with eon ftns UDisappmved <br />L <br />A <br />r urent With Conditions) <br />Plan Rerirevwers Na <br />DateL Z& <br />11 .. f Y •.Z-. •,-.,TJFIM r•:N •♦•-.• : ,;♦ J: • : • a;:. •• Y. .-...t,... ,:,q` Y. ...c „! '! r • ,a. •i t:*.h r: <br />•'t fes' • '� �. •: ... �. •: -. 1 •:1 ••. .. •.. .. �.: •. .. i• .. :-� ♦�' i ••: • •♦�• .. <br />•.�.J • • ♦ • • `.. •' ♦.. .. ' r .. �� :. . .:. •. • .moi'.: •:.:. .. • •.., �' ••. t"1 �. • <br />Indicate the responsible party to be billed for additional ERD staff tine expended beyond permit payment coverage per tank. if <br />the party designated below is different than the permit applicant, e.g. property owner, the party must aclawwledge this <br />responsit> 4 fofr the billing by signature and date below. <br />NA�a 1 <br />M4,33 <br />tE �L[l� TinEc�tP d I�e a,Ii , PiloPrE# 9 <br />5 - <br />SIGNATURES <br />EH23DO38 (revised 8!8106) <br />SIM <br />