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10/13/1997 15:41 818-840-6929 TRIANGLE ENVIRO INC PAGE 02 <br />10-13-1997 2 : 37PM FROM+ P_ 3 <br />• ENVIRCHMNTAL KALTH DIVISION • <br />SPK ICATIOX FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPINT, REPAIR PERMIT <br />THIS PERMJT EXPIRES 90 DAYS FROM THE APPROVAL DATE- 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PE9HI7 TYPE 3ELOW- <br />TANK REPAIR/RETROFIT TANX LININS _ PIPING REPAIR <br />EPA SITE I PROJECT CONTACT A TELEPHONE 0 <br />SiLLIXG INFCRMATICN: <br />Endiaare the resowmibte part' to be bitted for no1cfamt PNS-ew staff time expended beyond permit payment average pep Cants. If cbe <br />party designated Cetow is different than the peemie applicant, e.N- property ower, the party must acknowtedge ::tis responsioitiry for <br />me SiLCing 5y signature ted date betow. <br />Name--r&lAA;6Lu eIVv.P-VVin6N'T JNG <br />nai I i ng Addrzss gcp 5 3 S t.J 64 F? MiA N K 131. y o P>s-t f bAA11C C >s. 9 / SL' S- <br />Cav phone <br />Signature f..� <br />Eit 23-0038 <br />L d I w 9 �A*%� �Po o&v-4—. c,,,._ to -?.P 7 <br />F <br />A <br />FACILITY WANECh eCLe K - s y PHONE $ a o y_ s s - a r7 (20 <br />C <br />ACORESS -6 ;10 a vJ /•I A r'. P1 t✓ (z', L N <br />I <br />L <br />I <br />CROSS STREET <br />T <br />ouuCtIOPERArca <br />PHONE @ <br />Y <br />—7-0seal MAf-=Ki, -r)v , <br />(a0 - aLoo <br />G <br />0 <br />CONTRACTOR WAFSE-ml AN ENV%k0V"'IICVIA T!t/c_ <br />PRONE 5glo � _ 7+?c�D <br />V <br />T <br />CONTRACTOR ADDRESS plSa%s 1n/ �u� VD <br />CA CIC f <br />N <br />A <br />INSURER mut-Lkra-rokJ IkJS,4i2F•NLe 5 2V1C�� <br />WOftK.CCl'IP. SD3Do� (, <br />C <br />0TNE3 TNFORMATION <br />T <br />0 <br />P f <br />R <br />NONE f <br />1111!!t!!!I!!!Il1lfill !1111111 <br />TANK IO f TANK SIZE CHE?4JCALS STORED RRENTLTJAREVIOUSLY � DATE UST INSTALUD <br />39- <br />r <br />39- <br />A <br />39- <br />W <br />39- <br />a <br />K <br />39- <br />39- <br />tttl <br />APPROVED _ APPROVip ITION(5) _ RISAPPROvE4 <br />JNAL <br />ATTALNME=ITI0NSi <br />PLAN REVIEVERS NAME DATE <br />111111111111 Ill 111111 1111111111111flill 11111111111111111JHI 111111111111MMIN111111111111 Ill 11 Ill IMMIRTWI <br />APPL!CAHT MUST PERFORM ALL WORK IN ACCORDANCE VIM SAN IN COINITY =tmARCES, STATE LAMS, Ato RULES ANO REGULATI=s OF <br />SAN ICAOUIW CQUNTT PUSL:C HEALTH SERVICES. DIMER 0R AGENT'S SIGNATURE CERTIFIES TlIC FOLLOWING. "i CIRTIFT TIIAT IN <br />TXE PERF:RHANCc OF THE WORK FOR WHICH THIS PERMIT IS I , t SHALL NOT EYIPLOY ANY PERSON IN Svcs A PAlMMR AS TO BECOME <br />SUSJ!V TO L' KER'S CDM4ENSATION LAWS OF CALIFORNIA.• TRACTOR'S AIRING OR SUBCGNTAACTING SIGNATURE CMIFIL'S THE FOLLOVINa- <br />1 <br />"! CERTIFY THAT IN THE PERFORMANCI.' OF THE WORK FOR CH TAUS PERMIT IS ISSt1ED, I SMALL EMPLOY PERSONS MXJECT TO UORKP�2-S <br />COMP!XSATfON LAWS OF CALIFORNIA.~ <br />APPLICANT'S SIGNATURE : TITLE DATE <br />SiLLIXG INFCRMATICN: <br />Endiaare the resowmibte part' to be bitted for no1cfamt PNS-ew staff time expended beyond permit payment average pep Cants. If cbe <br />party designated Cetow is different than the peemie applicant, e.N- property ower, the party must acknowtedge ::tis responsioitiry for <br />me SiLCing 5y signature ted date betow. <br />Name--r&lAA;6Lu eIVv.P-VVin6N'T JNG <br />nai I i ng Addrzss gcp 5 3 S t.J 64 F? MiA N K 131. y o P>s-t f bAA11C C >s. 9 / SL' S- <br />Cav phone <br />Signature f..� <br />Eit 23-0038 <br />L d I w 9 �A*%� �Po o&v-4—. c,,,._ to -?.P 7 <br />