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02/24/98 14,55 NO.425 P02 <br /> ENVIRL*Xk;NiAL hiALIN DIVISION <br /> APPLICATION FOR U TANK RETROFIT, TANK LIKING, OR PIPING REOPERMIT <br /> THIS I;€Rgjj EXPIRES 90 DAYS FROM TIE APPROVAL DATE. 00 MOT IM179 IN ANY SWOED AREAS. INDICATE PERMIT TYPE BELOW; <br /> —TANK REPAIR/RETROFIT ___.TANK LINING JL PIPIN REPAIR <br /> .EPA SITE d PROJECT CONTACT It TELEPR <br /> F FACILITY NAME Afk *P?i I <br /> A <br /> C ADDRESS P–,n <br /> I <br /> L CROSS STREET Wrov <br /> I PHONE I <br /> T OWNER/OPERATOR <br /> ROSS STREET <br /> E OPERATM PHO <br /> r <br /> C CONTRACTOR NMI; PRONE ON TRACTOR <br /> 0 — <br /> N CWTRACTOR ADORERS CA LIC 194ftjfSo. CLASS if 6e <br /> CCXTRACTOR ADDRESS tj <br /> T — <br /> ir <br /> R I INSURER dt4 <br /> A i <br /> C I OTHER INFORMATION <br /> O P11 <br /> mw 0 <br /> PHONE # <br /> TV* 0 ff TANK SIZE CHEMICALS STORED OUSLY DATE UST INSTALLED <br /> EQ YIPREVI <br /> 39- <br /> T 39- <br /> 39- <br /> N 39- <br /> K <br /> 39- <br /> 1111 <br /> P <br /> L APPROVIi!) APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACWMT VI TR WHOITIONS; DATE <br /> X PLAN REVIEWERS NAME <br /> 11111111111111111111 ! <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORCANCE WITR SAX 4AQUIM COUNTY ORDIKANCESt STATE.LAVS, AND RULES AND REGULATIONS OF <br /> SAN JOAOU(N COUNTY PUBLIC HEALTH SERVICES- OWNER OR LICENSED AGENT'S 31GRATURE CERTIFIES THE FOLLOWING. "I CERTIFY THAT IN <br /> THE PERFORMANCE Of THE WORK FOR 'WHICH THIS PERMIT is ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MARINER AS TO BECOME <br /> suejEcT ic KEROS COMPENSATION LAWS CALIFORNIA." CWHACTOR'S HIRING IDR SIGNATURE CERTIFIES THE FOLLOWING! <br /> HE CERTIFY THAT IN THE PF MANCE Qf 9 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER-5 <br /> COMPENSA71ON LAWS Of CALI OR IA <br /> APPL[CANTIS SIGNATUREi TITLEDATE <br /> .9ff— <br /> BILLING INFORNATIUMi <br /> Inlicote the responsible party to be bitted for eddl tionat. PNS-END staff time expanded beyeW peWt payment coverage per tank. T f the <br /> party designated betow is different than the permit applicant, e.g. property wwr, the party mist acknowt*dge this res pwaWlity for <br /> the bilting by signature and date below. <br /> Name <br /> Mailing Address;96f) <br />