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Dec 09 98 09:46a <br />E <br />Elite IV Contractors Inc <br />4' NVIRONNENTAL HEALTH DIVISION <br />209-461-6342 <br />APPLICATION FOR UNDERGRCUID 7ANX RETROFIT, TASK LINING, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE- On RCT U21TE IN ANY SRAOED AREAS. INDICATE PERMIT TYPE 8ELCU: <br />YANK REPAIR/RETROFIT _TANK LINING . PIPIRG REPAIR <br />APPLICANT MUST PE71CR14 ALL WORK IN AC=DAN=- 4ITH SAN _CAOL+IH COUNTY OROIRANCBS, STATE LA6'S. AND RULES ANO REGULATIONS OF <br />SAV :CRCU Lv :MN TY %CSLiC NEAL7:1 SERVICES. OWNU OR LICENSE] AGENT'S SIGNATURE =1171-M THE FCLLCVING: •- THAT IN <br />74E ?FRFCRMAVCc OF 73E VCRK FCR VHICN TAIS ?!7417 IS ISSUED, I SHALL .MCT SMPLOY ANY ?E_RSCN !N SUCH A MR <br />ANNEAS TO 3E=ME <br />:US Cc 70 XRK<7'S CC.MPENSAT!CV 'AWS OF CAL:FCRNIA." CONTRACCOR'S :i I R:NG CR S)8CZN'•RAC!NG SIGNA71URE :e32:'iE5 T3E FOLL:'ING: <br />TSA• M- PERFORMANCE OF TRE .CRK FCR VMIC3 THIS PSRMI? :3 ISTUED, ! SHALL S+4PLOY PERSCNS SCE:ELC TO ':CRKER'S <br />CMPENSA•ICN •,.US OF- AL'FCRN!A <br />.PW:—NT'S is CNATURE -..L° 1 Y� 7AIc <br />i;L-:NC !RfCRMATICN: <br />:rdicar ^e resccrsibta Dar.-/ :o be billed for acdWona( PBS -?-0 s-ar? :'Gs r oemded b; y r6 Penic oaymenc ve,tge -or car.[. I: .]e <br />]2f :Y daS 9na f'_C :<low a -., lar3 c :nam :no Per'ei' ao=t;C=r' a.;. ertrer7/ ]user, _1e =F -.l a3: 2axneulaC4e :.11z rescensiCil'.C7 :cr <br />:.^.e :i _ in,C :ya S:9naC-r- arc date :e'aw. � <br />Mai LiN <br />;ay Phene Ntsmer �) <br />All <br />EPA SITE 9 <br />PRO'EC; CONTACT Y TELEPHONE i l <br />F <br />FACILITY NAME <br />PHONE <br />of <br />C <br />ADDRESS U/ / �•� <br />�^ay l <br />I <br />V <br />L <br />LRCS; STREET <br />f <br />I <br />T <br />CLNER/CPERATCR <br />PHONE 9 <br />Nq i <br />CO I <br />CONTRACTOR NAM <br />,4 <br />I PHONE <br />W4,337 <br />A <br />( CDNTRACTCR ADORESS ' ;J <br />IF'• <br />CA L!C <br />Oy I CLAY A-702 <br />I <br />i INSURER WA <br />zz <br />Am -y- NX U 7 3'/ <br />I ';'bDa9✓ 3 7 <br />J <br />C <br />RMA <br />OTHER INFOTICN <br />I <br />T <br />O <br />! <br />PHONE S <br />3 <br />II PNCNE '. <br />i t l l 11111111111 f 11111111111111 <br />i NK :0 <br />-ANK SIZE :AZCita $ <br />RED =RRENTLY/PREV1CUSLY I OAS INSTAL -D <br />1 1 1 1 (fT1TT1117iTCTTTTIiTT <br />iiiTTiTTITI <br />I [iTf711TiTitTT11TI tIi <br />� P <br />APPROVE' <br />APPROVES VITA:OYDIT!CN(S) <br />DISAPPROVE] _ �/ <br />A <br />E AT- NT WITH CONDITIONS) <br />_ <br />/% <br />/ / <br />N <br />PLAR 87ICVE7S NAME <br />DATE((pj/ <br />-1111111111111111lI11111 <br />I1 111 <br />1 I 1 1 <br />111 1 1 1111 111 ! 11111111111111 <br />1 1111 lllilllllll Illtillltllltll11111 Ili <br />APPLICANT MUST PE71CR14 ALL WORK IN AC=DAN=- 4ITH SAN _CAOL+IH COUNTY OROIRANCBS, STATE LA6'S. AND RULES ANO REGULATIONS OF <br />SAV :CRCU Lv :MN TY %CSLiC NEAL7:1 SERVICES. OWNU OR LICENSE] AGENT'S SIGNATURE =1171-M THE FCLLCVING: •- THAT IN <br />74E ?FRFCRMAVCc OF 73E VCRK FCR VHICN TAIS ?!7417 IS ISSUED, I SHALL .MCT SMPLOY ANY ?E_RSCN !N SUCH A MR <br />ANNEAS TO 3E=ME <br />:US Cc 70 XRK<7'S CC.MPENSAT!CV 'AWS OF CAL:FCRNIA." CONTRACCOR'S :i I R:NG CR S)8CZN'•RAC!NG SIGNA71URE :e32:'iE5 T3E FOLL:'ING: <br />TSA• M- PERFORMANCE OF TRE .CRK FCR VMIC3 THIS PSRMI? :3 ISTUED, ! SHALL S+4PLOY PERSCNS SCE:ELC TO ':CRKER'S <br />CMPENSA•ICN •,.US OF- AL'FCRN!A <br />.PW:—NT'S is CNATURE -..L° 1 Y� 7AIc <br />i;L-:NC !RfCRMATICN: <br />:rdicar ^e resccrsibta Dar.-/ :o be billed for acdWona( PBS -?-0 s-ar? :'Gs r oemded b; y r6 Penic oaymenc ve,tge -or car.[. I: .]e <br />]2f :Y daS 9na f'_C :<low a -., lar3 c :nam :no Per'ei' ao=t;C=r' a.;. ertrer7/ ]user, _1e =F -.l a3: 2axneulaC4e :.11z rescensiCil'.C7 :cr <br />:.^.e :i _ in,C :ya S:9naC-r- arc date :e'aw. � <br />Mai LiN <br />;ay Phene Ntsmer �) <br />All <br />