Laserfiche WebLink
ENVIROW4ENTAL HEALTH DIVISION <br />APPLICATION FOR UHD*ERGXCMOK RETROFIT, TAMC LINING, OR PIPING REPAY WHIT <br />THIS PERMIT EXPIRES 90 DAYS FRCS THE APPROVAL DATE. 00 NOT WRITE IN ANY $HADA AREAS. INOICAT'c PERMIT TYPE 8'cLC.'; <br />• <br />TANK REPAIR/RETROFIT TAMK LINING __ APING REPAIR <br />EPA S:Tc _' I PROSECT CONTACT 8 TELEPHONE <br />EFACiLITY MAME <br />PHONE <br />ADDRESS 0�5 <br />CRCSS STREET <br />CUNER/CPERATC <br />r R ` P4CNE <br />�g <br />CONTRACTOR MAA � G� <br />PHCME T <br />CCNTRACTCR A RETS <br />t CA i", A CLASS <br />(NSUR:R / <br />C22LCRK.CO`AP. _ <br />OTHER (MfCRMAiiCN E <br />?4CNE <br />A 1 � <br />-�{Ili{{II}I(}I{I}ili}(II(IIIIII1 ?`ECHE <br />TA-14KEDTANK. S:Z: I <br />CH_cAIC.%LSSTORED CJRREM'LY/PRE'/TCLSLT I OA7E UST ImS7ALLS: <br />"75il <br />�Y� 1 <br />IIII 1-1-11 TIT1111111 fIflifFITFFITI ITTMTMTTI ril ITTI I I I I I I I ffm- f <br />l i <br />APPRCVED AP?ROVED 1.11 7A C_YD[T-CY(S) 0[SAP ?ROVED <br />(SCE ATTACHMENT WITH COVOII:CNS) <br />?' ;N RE'/TET.ERS NAME <br />-�{(((till{fI{IlliiltlllllllllllIII{Ilt!llllitlillllllllllllllll{lll1111}IIII11 lIIIlI1IIIIIIiittllllllllll111fIIlIIl11I}illill <br />OATE <br />MUS, PERF -CRM ALL '.'CRY. (k AC=RDAkCr VITH SAN .:C'AcLirm C=114TY CRO(MANC:S, STATc , AND 2CC=e AVO 2°_ LAT:CNS OF <br />;AN 'CACUEN =LINTY PCSL:C 3ESLTH SZR'JTCS. -MER OR L'C=' <br />= =R.-Rv Cz OF - c _ {SE7 AGENT'S S:GkAiJRE CSZTiF(-ES THE F _ ;•� C_3T.:v THAT l ' <br />- AN '3E t,�RK IIS ? RMT. :S SSUED, I SHALL MCT eiP!-Y ANY PERS^ 3CL ATVG: (} <br />%:S. '0 .CREEK'S CC?!PEfSATiCa ^c =O �N :V SUC3 vAkkE3 AS TC 3E.OME <br />S C.AL:. RVTA. _ MTRACTCR'S :AIR:VG OR <br />^cRT:.. T..AI :V T:._ PE. -z-, !A.y - - _.A HIS ?E' SI:SC:VTRACT:VG S:GkA .'R� _E3T:?.ES THE FOLLS.JTVG:' <br />-'lSAT CN-r.ia CF.�:L:. ,RV' °' OR +HT T ;11T Sau ' [ SHALL rJP!^Y P93SCVS Silo E�. lu^ :CRKeZ'S ! <br />/ <br />3:GNATURE: ! 2 _ <br /><� <br />:TLS <br />C ce ...e r=s0crsf;Ce car -y ._ .e _ <br />- -z �cce:cec seven :es -sic zayrrent __ver_ge =er _snk_ [- _:e <br />.-e ze..mi. aceC:C=.^.c, _-;. :r--er Curter, - <br />=+ ar.0 case CeCcv. / e ar y sc aC.:cv:__, is asccrsiciC../ .cr <br />t �ry <br />^.q AG:!r!SS a 4 <br />=hone *_,=elPN} C <br />acure <br />3-aala <br />i <br />