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SANTA 7.UZ COUNTY HEALTH SERyICES AGEN' <br /> *. IRONPAENTAL HEALTH SERVICE I./ <br /> 701 Ocean Street,Room 312,Santa Cruz,CA 495060(831)454-2022 <br /> APPLICATION FOR PERMIT TO MODIFY A HAZARDOUS MATERIALS FACILITY <br /> [PERMIT EXPIRES 6 MONTHS,FROM DATE OF APPROVAL] <br /> ATTACH TWO COPIES OF PLANS ASSOCIATED WITH PROPOSED MODIFICATION" <br /> INCLUDE SPECIFICATION SHEETS.FROM MANUFACTURER WHERE`APPLICABLE <br /> 1 '041()2- t::23PM Or'OP#4900 DOM <br /> d PL0521 $233;00 <br /> ERMIT NUMBER: 02,7- EE PAID Y�38 ODDATE: $L'g' <br /> do <br /> CASH REGISTER VALIDATION <br /> :anon <br /> 5]S ChApp��IRoA� , ajsanva�l� <br /> cility:Name, Po CIlr\G APN <br /> ,net/Operator Poo (Y7,u Telephone gI25 823 SSE' <br /> ropertyOwneejr P1Ct�'1C. Lt� Telephone 925823 $866 <br /> ..*ractor t"s <br /> ddress 39o9 POP-k- ROAD , &A%C�r, Clq q�tsro <br /> TAenseNumber 63q Telephone WO g(41 <br /> 'ner/Builder Declaration submitted: [ ] Yes [ ] No N Not applicable <br /> IODIFI ATION BEING PROPOSED: <br /> all equipment proposed attach manufacturers specifications sheets, and installation and maintenance instructions. <br /> _materials of construction must be compatible with materials stored. <br /> Monitoring Device/System ❑ Overfill/Spill ❑ Secondary Containment Structure <br /> (Attach Monitoring Plan) Protection (Attach capacity calc sheets and <br /> identify materials of construction) <br /> Repiping ❑ Aboveground Tank Other <br /> Tempofr2tA OJQ%a&1c Qellon <br /> D1�5P k <br /> 1 Fsk- Alis ac IL/- <br /> I I-27-of <br /> TITLE DATE <br /> 5W4(A CRUZ CNTS' ___ _=___ <br />