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10/13/1997 15:41 818-840-6929 <br />4-13-1997 2:37PM FRO* <br />TRIANGLE ENVIRO INC <br />0 <br />ENVIRON"INTAL HEALTH DIVISION <br />PAGE 02 <br />P. 3 <br />z APPLICATION FOR UNDERGROUND TASK RETROFIT, TANK LINING, OR Piping REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE_ 00 NOT WRITE IM ANT SNARED AR94. INDICATE PERMIT TYPE RELOW: <br />l� TAXK REPALR/RETROFIT —_TARK LINING _ PIPING REPAIR <br />EPA SITE I PROJECT CONTACT i TELEPNONE # <br />F <br />4 <br />FACILITY NAME <br />C <br />I <br />ADDRESS aLj a p -,, A3 taiz,, LN <br />` <br />L <br />I <br />CROSS STREET r✓ Lt_ p <br />T <br />OUNERIOPERATOR <br />PHONE # <br />YSc <br />t� rn�f�.xb r�N6 <br />40a - aoo �1 3C7 <br />C <br />D <br />CONTRACTOR NAt1! -T'P-1AN6C..5 ENVte-0k1MtVV-fA(— <br />R!Vf, <br />PRONE # <br />8lO- 70 d(� <br />N <br />T <br />CONTRACTOR ADDRESS ash &iK6AN< 6L -VD <br />CA CIC it -3 t? - 7 1 <br />CLASS <br />a <br />A <br />INSURER f=u�ltJ27pJit 1N)SNaFNet? 5tt-Avte(ra <br />UORK.COMP.1 tv <br />C <br />OTNE3 INFORMATION <br />T <br />0 <br />P"s I <br />R <br />PHONE # <br />I11111111111fill 11111111Ui111 <br />TANK t 0 TANK SITE <br />CHEMICALS STORED CURRENTLTIPREVIOUSLY DATE (IST INSTAL1,0 <br />39- <br />� <br />r <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39 - <br />i <br />AP ED APPROM U178 CONDIVORCS) 0ISA"1040 <br />A pl �WtT;&;;�i WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />11111111111111tIII tl t til I If1 Mill 1111111111111111I U t Ut111 i i 1 <br />APPt:CANT MUST PERFMM ALL WORK IN ACCINIOARCE 4IT9 SAN JOA1JU1N C*XTY ORDINANCES, STATe LAYS, AND RVLES AHD REGULATIONS OF <br />SAN 10A2111N CWNTT PUBLIC "ALT" SERVICES. OWNER OR LICENSED AGENTIS SIGNATURE CERTIFIES THE FOLLOWING. "I CSATIFT THAT IN <br />TO PERF:.RNANC` OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A i11►iiNER AS TO BECM <br />SV6JECT TO 4ORKER'S =WSNSATIOII LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE' OF TNM WORK FOR WNICHM THIS PERMIT IS ISSUED, I SHUL EMPLOY PERSONS SUBJECT TO UMER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE! ► 3 TITLE VfN, .Q 6e -K-. DATE /0t 13JR-1 <br />914LIXG IHFCRMATICN: <br />Inditare the respoAsible party to be bitted for sWItfonst PNS-EHD staff time expended bttwW permit payment coverage per tank. If z.4e <br />party d -e. israted i etow is different than the Mmit SMUCant, e.9. Property owner, the party must acknowledge this responsiniUry for <br />the b4L(-?ng Syr signature and date baton. <br />Name IAAl6Lir�IV.1%R.1)N,Jfn6N"T HNC, <br />Moi t i ^B Addresf. OP 15 Q 5 �(G� fes`% fj�l RCSr� � K 84. V t -> Pj(� P.®i�nf>� C,, P" <br />tav ?hone' NtAt7e• (y) �/ J� <br />'- <br />c <br />