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ENVIRONMENTAL HEALTH DIVES <br /> ton <br /> FOR UNDER TANK RETROFIT, TANK LINING, OR PIPING <br /> THIS P=;MIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. PERMIT <br /> DO HOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW; <br /> __TANK REPAIR/RETROFIT __TANK LIMING <br /> P PING REPAIR E?A SITE , I PROJECT CONTACT $ TELEPHONE <br /> F FACILITY NAME <br /> A <br /> PHONE Q _/ - <br /> C ADDRESS J <br /> L CROSS STREET <br /> I <br /> T CWMER/CPERATCR <br /> Y PHONE <br /> C I CCN TRACTOR NAME <br /> O I PHONE N <br /> M C7NTRACTGR ADDRESS <br /> T <br /> a LIC : I cLAss �J"%Z <br /> A IeSUR£Ro <br /> /c-U T <br /> I C OT4ER IN ORNATIGN I c� <br /> Q <br /> PHONE <br /> I <br /> 111III111111111111111111111111 I PHONE <br /> TANK ID # TANK SIZE <br /> 39- I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br /> 39- <br /> A 39- <br /> N A9- I <br /> :c 39- <br /> ,9. MTMTMTMTMTMTMTWi f <br /> i <br /> 1111i <br /> 1 <br /> APPRCVED _ APPROVED WITH CCMDIT!CM(S) _ <br /> CsEE ATTAC.HMEMT WITH CCBDITIONS) OVED OISA?PR <br /> N <br /> PLAN dE'ItEWERS .NAME <br /> DATE <br /> lllililllllllllil111111111111111111111111111111111 11111111 llllilllllillltil 1111111111111111 111111111ll11111111111i111J11 <br /> APP!!CANT MUST PERFORM ALL LURK IN AC=ROAHCE WITH SAN JCAOU14 COUNTY CROINANCBS, STATE LAWS, AND RULES AND REZ 1LA-,iCNs OF <br /> SAN -'CACU(N :OUNTY PL'BL!C HEALTH SERVICBS. C.•AER OR L:CeNSED AGENT'S SIGNATURE C£RTIF:ES THE FQL!CW(•VG; THAT IM <br /> TB= Pcac.CRMANCE OF THE %=X FCR WHICH THIS PERMIT IS ISSUED, I SHALL HOT EMPLOY ANY ?ERSGN IN SUCH ' V <br /> SU9^_- G !'^RXER'S CMP£45Ai IC:7 !AWS Of CAL:FCRNIA," CONI RACTGR'S MIRING OR A MANNn AS i0,3ECC:1E <br /> THAT !4 THE PERFCRMANCE GF THE 'ARK FCR WHI eR SUI SHALL EMPLOY SIGNATURE <br /> C:i THIS ?_.YI7 !S ISaUED, ! °• LL MG <br /> C=NPE:HSA I:ON !.4W5 GF CAL:FGRV!A.11 SHALL EMP.OY PERSONS SUB:E=T TO ':CRXER'S <br /> APP!:CANT'S SIGNATURE: <br /> T i TLE OA7E 7 J <br /> I <br /> 3ILL:NG !HF^_R.4Ai!ON: <br /> .rcicaca -ne rescensibla ;arty ;e be bide: ror acdicien-al PHS-ZH) star= tics axcenCed beyond <br /> __=1 ces:_na ^_ below is d° r=renc c-an :^e pe^it accL:eant, a _racer./ tuner, ae <br /> per-Iii oaymen: cove.^age per c3nk. I2 c1e <br /> ..._ of Ling dy si gnscl4re and dace belcu. '- - Parry .nst acx:.ewledge -.-.is respensibilicy rcr <br /> flame <br />.`!ailing Address <br /> lay ?hone Member (_) <br /> 3igracure <br /> E:i �=-•70:d <br /> t <br />