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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGO <br /> NDERG TANK RETROFIT, TANK LINING, OR PIPING R PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE (iELCtd: <br /> _TANK REPAIR/RETROFIT __TANK LINING IPING REPAIR <br /> EPA SITE Jp L/ ( PRO.:ECT CCNTACT L TELEPHONE <br /> A <br /> F FACILITY NAME PHONE R� ' <br /> A <br /> C ADORESS <br /> L CROSS STREET <br /> r <br /> T CUNER/CPERATCR PHONE ". <br /> T67/OD <br /> C I CONTRACTOR NAME I PHONE . <br /> 0 + <br /> N CONTRACTCR AOORESS t CA LIC a <br /> CLASS <br /> R INSURER /® <br /> A AH YJ Gp7-3,543 <br /> R Cr .: �g <br /> C OTHER tNFCRMATiGN I ! <br /> Z PHONE <br />--ilIl[ilI1Il1IIIl1IIti11tIII1II1 I PHONE <br /> - <br /> TANK (0 <br /> 39- <br /> TANK SIZE CHEMIC,%LS STORED CURRENTLY/PRE'/iCL:SLY ` GATE UST INSTALLED <br /> -• i E <br /> i 1 I I P�ITi'tTT1 (tI7)•IITI�TT17lZTrITTT{ <br /> L IPPQcvE� AP0R D " - CcNDITiCm(�S) DISAPPROVED <br /> N PLAN RE'!t='aERS HAMS DATE le. <br /> Ar T <br />--�IlifIi1111111111111I11111I11illlllli111111i1111I11111 It I III it lilt 11i111IIIIIiIII}111 1111 IIIIIIIIIIIIIIillI1I1 <br /> _PP!ICANT MUST PERcCRM ALL WCRK IN AC=ROANC_ WITH SAN :CACUIN C_-LINTY CROIHANCES, STATE LAWS, AND RULES ANO REGULATIONS OF <br /> SAN ICACUIN COUNTY PUSLIC HEALTH SERVtC_S. Cl-?tER OR L:CTASED AGENT'S SiGHATUR£ CERTiii'c5 <br /> TTIE =CLLC:tYG: "t Ti=Y THAT IN <br /> HS ;?2FCRvANC_ OF T'E '.ARK =CR '.:HiCH 'HIS PERMIT IS ISSUED I SHALL NOT =MPLOY ANY PERSON :N SUCH A MANNER AS TO 3ECCME <br /> TO -CRK=?'S CCMPEN - , r t _ _ <br /> ' SA,:CN �,.»S Cf CAL:.c.RNtA. �NTRACTCR'S :iIR:N ^, <br /> ?" THAT tN T=S PcRP_RMANC_ CF Ti£ ':CRK "JR �HIC:i TA* PcR rG 'R SUBC:VTRACT:NG S:GNA ,'RS _.R :, .ES i:'.E =OLL�'ING:: <br /> LAtIS 'S MI� :S SSLED, I SHALL �iPLOY Pe3SCN5 SUfi_c iG ;CRKE3'S I <br /> Aa?L:CANT'S S:GNATURS <br /> ITEC GATE <br /> L' :NG :NF�RMATtCN: <br /> CiC3,_ r=sccrs:�ta car-y :o =e oitt for additiorat PyS-=-D star' .:.e excerd <br /> r-y ..s ee3te: _e'zw ed .eycnc er•sit Raymer. _overage der :ink. If w.e <br /> =^e ::'.an :Ze re-si_ ac^t tCant, e.,- or ^-y as.ner, ; e .arty mLst acs .cat:^ <br /> e date ce e is r s^cnSioi .;y .cr <br /> me <br /> ding Address <br /> Y ?hone Nc-*mer ) <br />;riacure <br /> Z <br />