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HEAL: DIVISION <br /> •�.'� APPLICATION FOR UNDERGRO :ANH RETRCFIT, CR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM wE APPROVAL DATE. DO NOT WR:TE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELO <br /> C' Kai,- PIPING RE-PAIR <br /> EPA SITE # j ?RO:,ECT CCN,-ACT 6 TELEPHONE 47 <br /> i .ACIL:TY NAN.E PHONE . c^'7 <br /> C I ADDRESS <br /> CROSS STREET L7/•�- <br /> . ( OWN O?:: n ! —ONE� ! <br /> j _c:.Ac OR , REss /'► a I __ '�G�' I G, 1 " C6 I <br /> .v -4 <br /> /�Y1 ' �� f' j tic-.x._ Na.,S�I f7t <br /> ! ?HONE # ! <br /> — Illlllilllllllilllliilllltti!1 <br /> 1 TANK IJ = I ...�'.• n:_c I �P.EM_ .i.5 373RT-D C,77;-71;LY/PREVIOUSLY I :;ATE U 'NST?_..:.c0 <br /> A I 39- i I I I <br /> =9 <br /> -11111111111111111111111111111111111111111111111�1/1'11111111IIliiIIIIl1111111111111111111111111111111111111111IIii111111I11111111I <br /> APPROVED7l A?r-C✓ED 'rl?':: =vD7'i)1TiON�Si DISAPPROVED 1 <br /> A I Z'!SEt A:`.AC:'_''<EA; W CC�^,.1TT_O15i <br /> —illllillll'l.lclWiE: �• ` , ( CQ S 111111111IIlili111111111Ii1SA1T11:AU lIm 1111FI T 111111111 1111 u11111111111111"1]1111L�111/1r1111/11/ <br /> IIIII1111111 <br /> MUST =ERFCR, ALL WORK :N ACCORDANCE WITH SA-N :.OAWIN =CLN7Y ORDINANCES, STATE LAWS, AND RULES AND REGULATION'S OF <br /> i\ OOACU:N CO-^7 ! ? LC S. RVTCES. OWNER OR ..:_3\SED AG'T-VT'S SIGNA-',:R3 CrERTIF:r-S THE FOLLOKi`.G: "I CERTIFY THAT :N I <br /> .r.- ?ERFCRMANCE OF THE WORK =OR THIS ?EzM:7 _S __S.aD, _ S::ALL NOT 2!?PLOY ANY PERSON IN SUCH A Y.ANNER AS TO BECOME ! <br /> .-...CECT TO WORKER'S COM?ENSA7:N LAW OF CALIFORNIA." _ONIRACT:R'$ -:R::7G :.R SL3CONTRAC::NG S:GNA^ 'a _n. _ _n5 TH FOL:,OW::7G: <br /> _ERT:?': THAT IN ?c= E THE WORK FOR WH:CH THIS PERMIT. :S ISSUED, : SHALL EMPLOY PERSCNS SUBJECT TO WCRKER'S ! <br /> _OMPr-NSA --SN SAWS O' CAL: <br /> .::Pte:C:i1.'S S:G1„T' E: • j '�c=O.T- :�/L'FNl'� �A77 <br /> BILLING INFORY.ATION: <br /> =ndicate the respcnsible partyto be billed for additicnal PHS-=HD staff_ time expended beyond <br /> _ermit payment coverage per tank. I= --he party designated below is different than the permit <br /> applicant, e.g. propert_,r owner, t^e part.✓ must acknowledge this responsibility for the billing <br /> -may signature and date below. <br /> :3amP �/ik_ f,, acdressS'`w17- 1.'1 � ^.cne r_umbe= c'. f c?y3 " <br /> Signature <br /> �d 23-0038 t�►s�e'� ��• <br /> 40 <br />