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ENVIRONMMAL HEALTH DIVISION <br />APPLICATION FOR UUOERGRCUU&K RETROFIT, TANK LINING, OR PIPING R£PA RMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK REPAIR/RETRCFIT __TANK LINING PIPING REPAIR <br />E?A SITE aI PROJECT CONTACT & TELEPHONE %Jfj l <br />FACILITY NAME G / <br />ADDRESS <br />CROSS STREET <br />CGNER/CPERATCR A a d <br />CONTRACTOR NAME' <br />CCNTRACTCR ADDRESS <br />INSURER 1 <br />OTHER INFCRMATiCN <br />III IH II]Ill III I]IIIII111I1111' <br />TANK ID <br />�9- <br />JY' <br />JY - <br />JY' <br />J7� <br />�C- <br />JY' <br />llII <br />PHONE 9 (c, <br />PHONE ' <br />(! J- PHONE m <br />ell <br />CA LIC A I CLASS <br />WCRK. CC.MP . _3 — <br />PHONE <br />CP4CNE T <br />TANK SIZE ( CHEMICALS STORED CURRENTLY/PREVICUSLY <br />I <br />1 <br />I <br />APPROVED APPROVED ':tTH cCVa[TICNcs) DISAPPROVED <br />(SE: ATTACHMENT WITH C::Nat1I0NS1 / <br />H ?SAN .2E'/t=UERS NAME OAT^c ! <br />-tIIlI1IIIfIil1IIIII11I11 lilli]i1111II11II111I111Ii111i111111411111111111 Iti111111(illliil1111 II lll1ll 1111I1111111111I <br />^ppt r -ANT MUST PERF -ORM ALL 'XRK IN ACC RDANCF 112TH SAN 'CACUIN CZ -LINTY CRD[NANC_S STATS I�:LS, AND ZU6 3 AND RE_ULATtCNS OF <br />SAN ICACUIN COUNTY ?L'BL[C HE—LT-H SCR11tC:4. C•NER OR L:CEASED AGENT'S S[GNATURE CERTiF;ES THE FCLLC-'ING: "t CERT; FY THAT IN ' <br />THE ';R`CR.!ANCE OF THE XRK FCR ',H[C.i THIS PERMIT tS ISSUED, t SHALL NOT _..MPLOY ANY PERSON [N SUC:i MANNER AS TO 3ECCME <br />SUBJZ_T TC :CORKER'S C:kPENS:.T:C:d `JS CF ^�LI'CR4I1." C^NTR I r <br />?c?_ _ _ AC?OR'S :i ZING R TiIBC:NTRACT:NG StGNA �'RE=�T;",�S THE rCLLCrNG. <br />CC ?7THAT [N T:" :RMANC_^ F THE 'XRK FOR ,1H:C:i T , ?E? r AL_ EMP S SUB..E_. iC :CORK°R'S <br />C P_:fS:T.CN L..;'WS CF H,S MIT IS S�UE7, S' LAY ?EZ_C?t5 I <br />l <br />S:GNATURE: e L^ <br />C. <br />m <br />DATES UST INSTALLED <br />i <br />1 <br />I � <br />I I <br />LL <br />:NG [NFCRMATtC`d <br />Cic3c_ r=sccnsioie Cary ce Silly+ .ar acditioraL ?'IS-= -Q 4 <br />ry ces gnac- _.�w ci , e -^ -3D star ...;a axce: cep c yme^.- g <br />is enc nan m e._-emi: ac^Licant, a cr^^ter .wn -4e ;a r pe;sz ca .verse :er tank. -ce <br />e CI l'.;na ['_.. nrH caro ®t•^.� .y'. -�/ a^i e ;.ar:y .B.'.St 3CY.:;CaI�C?@ .'1S i eS^CfS'atL::f ,Cr <br />iLing Addriss <br />y Phone NL=er <br />gra cure <br />23-•M-78 <br />1 <br />