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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date March 21, 2012 OFFICE USE ONLY <br /> To: San Joaquin County JOB# � (� 1pp C_�< REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> San Pablo Bay Pipeline Company LLC VALID TO _ DRIVEWAYS: <br /> (Applicant Name) STREET \Jay- <br /> c/o Shell Pipeline Company, LP AREA -1�r—r V QUAL) <br /> Attn: Michael Elmore, senior'Staff Land Agentp <br /> TYPE <br /> (Mailing Address) FORMS ��IA)l dL ag2e- ��j���,'s <br /> 20956 S. Wilmington Avenue NOTES ( �� <br /> Carson, California 90810 <br /> (City,State,Zip Code) <br /> 310-816-2208 <br /> (Area Code•Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> i <br /> Exhibit "A" - prior Encroachment Permit 67-214 <br /> Questions - Please contact Beth Bissell, Contract Document Specialist for <br /> San Piablo Bay Pipeline Company LLC <br /> 925-9:35-5101 t <br /> I <br /> Theygdersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 6 side of Ec��a approximately %Z .#ertlmiie � <br /> of C M11 by performing the following work(description of work): <br /> to operate and maintain an existing 2011 crude oil pipeline crossing roads at <br /> locations shown in prior Encroachment Permit 67-214, a copy of which is attached <br /> as Exhibit "A". <br /> Work will commence on or about for approximately days. <br /> I,the undersigned,certify tha am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> ed above in rdancewith the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> fgnatu a of piicant•fitte Date <br /> J=am ,`'' � i 01 e-t-c_ _ <br /> E.SPU&SY.WWASTERPS%ENCROXaWEN'l PER'D'tP MCAM.2.WC{dll�j <br />