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• `� T ' JRM-16.2001 J10:531 F.02 <br />APPLICATION FOR MMRACROUND TANK RETZGrfT, OR ?IDIMO RVCAT.T PERMIT ,I <br />V"is MMIT 1TKPIRes 7o bAYS FROM, TRZ OVAL DATE. !DO NOT WRIT¢ IN ANY SIUIJED ARCAO, IMDICATE PERMIT J'YPi xxwwt <br />TANK RETROFIT �- PSPLWlI REPAIR .� <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHD staff dime expended beyond <br />aezinit ,payment coverage per tank. IE the party designated below is dlffez,�nt than the permit <br />dpylicarit, e.g. property -owner, the party must acknowledge this responsibiljty fel: the billing <br />by .eigiiature and date belbw. <br />NemA w),_FAC Nf, addressi�Zyy .ey � �1ohcne number Z.C't r{Q/ g:.-;, <br />- <br />Signitu <br />� ! 7.3 •. O'Q3 R Se-ir,a..EQu-i i:.• f '� . <br />Z • G��n- 11-u ,A-( rn,, s L.�.,f� �x- l ara _ a..� of l z C•'jCA- <br />✓� c�.�e� rn� �i <br />Ad <br />... ' • � - %{ � '�j�� cr� s rte• y 1 -� �,, �'� <br />TOTAL P.02 <br />F FACILITY MV11 � <br />�S P4OMB R Itvq� <br />A <br />,�oRrss b 2�4 <br />— I! J <br />1 i <br />I <br />- - <br />cROSs "PEET <br />j <br />I s <br />OYMRR �y - I ►40N! ! AW �a <br />C GOMrii�6lOx b l <br />r <br />+moi""�4 <br />•1 <br />N COMIRACfOR ADORES' <br />CA LIC I ��, �� I CLAVItI «/ <br />T <br />�J <br />A <br />C 1 OtHER IlIFOFWI►TIOaf <br />j � <br />0 <br />I PHONE M <br />1 ?NONE <br />INti�fl'[l111llillllllflillllll) <br />TANI IDR <br />TANK SIES C4:MIC STDRED Ct"rWnT/PM1OU6LY :.I DAIS Q:T' IAST7LLLM <br />» <br />�PA) <br />!~ GAF <br />If - <br />--- I <br />I <br />r if- <br />JI• j I' j <br />ITTiTTI11T TillTiif 1111iiI1Tii11TY1T�TTiti1TTT <br />F <br />7 <br />y/►P- <br />r— <br />�n 7ISAP►ROV=D <br />A <br />Y � Ri1V"WzRb NAME ✓ j <br />� A7TaC�1�1iT wLT4 CGNDITIOMII I I <br />IMT' <br />412f11111N111111ifIII <br />1111iliTtiliiliil't 1 1 iiiiiiTTifi]111111 <br />"PidCA'N't" Noir pim-aRM ALL MORE S:S ACCORDANCE -IT" SAID--CAOUIN COURrY 7ADIF"CES, STATL LAWS, AM Rmics A¢A ti5GOI.A1r:M 0►' <br />gAll'1JOAa3M A--euM CU/LIC HEAL:R LSRVICES. <br />r)WNEt OR •.::TNl�ED AGENT'S 5:6MA."7E CtRTIrics Tus ►OLLOwINC7 �rz C"'rTry 7!MT IN 1 <br />wCR 16 ?ERlt!! II ; S-=, I SHAL4, VCT EMMOT ANY r_RRON IN SVC. A `sA�l1R AS Te iiC:MI6 1 <br />TIIE'PyjIF7RMSA>�Ci jr "t110RK FORKI <br />36%I*CrTo IIORRTIR'S COM►EWSATTon CANS <br />CALIFORNIA.' '?NTZACTOR•S V:R-NG ;R -11MCONTRAc_:"M lIGXATIIRi �(;,TSfT� TTS FOLLOWING! <br />'L C£IIT>rk TftAT IV TRi PERF CE <br />NOR Mi ,' -OR wTAIS FEAM17 IS ISEUBJ, SML IMPLOY PERSONS SD(VEC: TO yDRKm -s <br />:Clflio<s7rl{IaR LAMS or 'FO <br />APPT.ICPM'�'"• iIQ1FA:TMs� <br />. _-�Z ��-19,�����lrTt��Q � OATS I`' '� � ` <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHD staff dime expended beyond <br />aezinit ,payment coverage per tank. IE the party designated below is dlffez,�nt than the permit <br />dpylicarit, e.g. property -owner, the party must acknowledge this responsibiljty fel: the billing <br />by .eigiiature and date belbw. <br />NemA w),_FAC Nf, addressi�Zyy .ey � �1ohcne number Z.C't r{Q/ g:.-;, <br />- <br />Signitu <br />� ! 7.3 •. O'Q3 R Se-ir,a..EQu-i i:.• f '� . <br />Z • G��n- 11-u ,A-( rn,, s L.�.,f� �x- l ara _ a..� of l z C•'jCA- <br />✓� c�.�e� rn� �i <br />Ad <br />... ' • � - %{ � '�j�� cr� s rte• y 1 -� �,, �'� <br />TOTAL P.02 <br />