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EMVIRONME?ITALHEALTH DIVISION <br /> APPLtCATICN FOR UROERG20 <br /> 0TANK RETROFIT, TANK LIMtMG, OR PIPING RE#PER.KIT <br /> THIS PERMIT EXPIRES 90 DAYS FRCM THE AP92CVAL DATE. 00 MOT WRITE IN AMY SHADED AREAS. INDICATE PERMIT TYPE SELC.d: <br /> p� TANK REPAIR/RSTROFIT __TANK LIMING . PIPING REPAIR <br /> EPA SITE <br /> 01 PRO.fECT CONTACT & TELEPHONE 9 <br /> FACILITY HA{E <br /> PHONE <br /> ADDRESS [ �( <br /> CRCSS STREET <br /> f C"ER/CPERAi <br /> PHONE T <br /> CCHTRACTCR N-4E <br /> CONTRACTOR ADORE�� CA LTC '. <br /> q� ! CLASS <br /> � INSu2ER ® _ <br /> � Qi3eR (NEv'RaAT:CM <br /> PHCNE a <br />-�II1i(iIIIIt11IIItI1II1IIlI1liI P4CNE <br /> TANK [D a TANK Si�E <br /> ' E tICALS STCRED C:'RRSN7LY/PRE'1ICL'SLY DATE UST INSTALL 2D <br /> 39- <br /> 111111fil If j � f <br /> ! f H1111111111111 1HT; <br /> APP2CVED APPROVED 'a 7X CCND[T:CN(S) DISAPPROVED <br /> .ZE'/[=:E?S NAME (Sc2 AT?ACXMENT WITH C:NOIT:CNS) <br /> OATE <br /> I1lIIfIIIIfItII11III1lll#t#!Il!#IlIlllltlilllllllI!!I!1#lllllllllltilllllllit I!#!!lllSllIlli!1111!lllllilllflllIllll!llll!#! <br /> APL:C.;NT MUST ?S :C2!4 ALL '.'CRK IM AC=2DANC= VITH SAN .CACUIM c:tmTy C2D[MANC=S, STATC !�.:5 AND 2UL=a' AND 2E LLATiCNS CF <br /> AN :C'CU�IvAVC_uTY 0F ?y'SLIyReE_L'i SE3.'[C=S. ,C 7{E2 OR I.:C;MS`cJ AG'cYT'S 5(GiAiJRd C=Z?i=:' LL_:[N :'r =Y 'TAT Y <br /> .R , :S PERMIT IS SHA <br /> 'u .CRK2.'.'S :�!PEJSATCC:d '_AL _ _, tA." C Y?7' L YOTVG-IP rY AM7 ?E3SCM ;Y SUCH MANNER AS Td 3'c=C"E <br /> ---- S .AL:. .RN RAC�CR•S AT ^ <br /> :N ?co" ANC= OF THE ':CRK "O2 :HIO:? THIS ?_' r SL8C,4T72,:C-:YG S:GNA'.'Re _=R-:F.2S ".iE ;CL`_ •:VG:`. <br /> 7-mP_A-AI.ON'LAWS OF L:• _ n." :`fI? :S �uED, I SHAL: -SCNS SUE.:==T TC 1XI.IZER'S F <br /> i <br /> �A7E <br /> C <br />:MG :sF.R�Ai Cv: <br /> e::e ..._ res:ans;hla .3r-% .e Oitl .ar ac�i�icrai P4S - <br />•/ __s.c^a_-- -' _u ...,-.e excer.ce^ ..eycra* :er-cis CaYrree^.. __.er3ge :er :ank. <br /> s - ^e -e-ii- t, ;. Cr^^mr,/ purer, e <br />'1 ..^•C �� S:ze;--w _ 3nC'^3L9.0--el <br /> V2�n .. 3¢^17c3.^. , :.`.e ar'_% .ZS: ac :-Cvt__= ...;5 .'SCCr.S tOi!.:% .C. <br />:ng AC.'.ress <br />=hanc Nt_[sCer <br /> aCura <br /> 3-•70�d <br />