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ENVIRONMENTAL.HEALTH DIVISION <br /> APPLICATION FOR UNDERSUO TANK RETROFIT, TANK LINING, OR PIPIRGWR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. <br /> INDICATE PERMIT TYPE 8^eLCJ: <br /> _TANK REPAIR/RETROFIT __-TANK LINING <br /> - <br /> EPA SITE 9 I PROJECT CONTACT L TELE NONE " / PIPING REPAIR <br /> F FACILITY NAM< ustl/1 /' �O <br /> CADDRESS / PHONE " . <br /> I II <br /> L CRCSS STREET Q <br /> i I CUNER/OPERATOR <br /> T PHONE <br /> C I CCN iRACiCR NAME <br /> 1- - 5 X13 <br /> O PHCRE t - ��� <br /> N CONTRACTOR ADDRESS I l ooCC <br /> CA LIC : I ECAs; _ Z <br /> R INSURER <br /> C OTHER INFORMATION <br /> i <br /> 0 <br /> .R I PHONE <br /> lllllllllllllllllillilllllllll I PHONE <br /> RANK to 4 RANK Si:E I <br /> 39- <br /> CHEM t C:LS STCRED CURRENTLY/PREVICUSLY I DATE UST INSTALLED <br /> T ]9- <br /> A 39- <br /> I :C ]9- <br /> '9- <br /> ]Y- <br /> fill MmTmTmTmTmTmTm7mmi <br /> mTmmTmmn <br /> 'K APPROVED APPROVED WITH CDNOIT1,CN(S) _ DISAPPROVED ' <br /> cE AT"CHMENT 9ITH CONDITIONS) <br /> -41 PLAN .2E''![cUERS NAME /� <br /> -,11111111111111111III iuiui�IullluIII 1111111111l3NlY4lllllllllliIAT <br /> lillllllll 11 111111111111111lllllll llllllllllllllll1111 <br /> .P PLrrANC MUST PERFORM ALL U'ORK IN AC=RDANG WITH SAN SCACUIH COUNTY CRDINAHCES, STATE LAW4, AND .2L'LES AND .2E•_'L,ST:ONS Of <br /> .AN —CACUIN COUNTY P'UBLtC HEALTH SERVICES. C.'NER OR L:CENSED AGENT'S SIGNATURE CERTI FiES THE ANDFOZqL IMG: "I ^-- THAT (N <br /> ._° ?92 F:RMANCE OF THE =r.RK FOR UHI C:i 'HIS PERMIT IS ISSUED, I SHALL .NOT ENPLOT ANY PERSCN IM TUC:{ A MANNE3 AS .. 3-E:DME <br /> JE-.__.-C :CRKER'S CMPSNSATi C:! LAWS OF CALLFORNIA," =XTRAC-CR'S 3IR:NG OR Sl:BC:.VTRAC7ING SIGNASUR- E THE ^ LL:IVG: <br /> ca. .:.' THAT IN THE PE=F:RMANCZ OF SHE ':CRK FCR L'HI e E TR °ic` O ry <br /> C:i iHIS i_RMIT IS !$SUE], t SHALL E9P!CY PERSONS SUH:E:- i0 ':CRKER'S <br /> P EISA I:ON LAWS OF CAL:FORMA." <br /> ADPL:C,:Ni'S SIGMA RUBE: <br /> DATE <br /> iILL:NG rNF:R.MAiION: <br /> .r.'icaca ::Ie resCCnsihle Carty :C Se biLLzc .Cr acdi rienai PHS-230 s:arr ri„a esoer der `xycnc xra:ir Zaymenr cove.^age ?er :ark. i' Cie <br />:Err/ res;cna cec ceLCw is ci"ererc aan ;ae per,i- ac^Lic�nr, <br />:ce Cn('i nS cy Signa car: an care 'ceLow. =rCcer^/ Curer, rte ;,Err/ .n(:Sc acxrcvlec;e :Dis resccrosibiLi:y rcr <br /> Name <br /> MaWnq .ccresS 53S .y l_"GL sZ o <br /> ii <br /> lay Phare N=er (.,0 9) <br /> S i;ra mre <br /> E3 *-70_a <br />