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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDEROD TANK RETROFIT, TANK LINING, OR PIPING 01R PERMIT <br /> THIS PERMIT„EXPIR£S 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE 8ELCW: <br /> _TANK REPAIR/RETROFIT TANK LINING PING REPAIR <br /> EPA SITEWo <br /> I PROJECT CONTACT & TELEPHONE y. r fy Oo% <br /> F FACILITY NAME PHONE /� <br /> A <br /> ADDRESS <br /> I �- 9 Cot- <br /> L CROSS STREET <br /> I c. <br /> T ( CUNER/CPERATCR PHONE 4 <br /> C ( CONTRACTOR <br /> 0 <br /> / PHONE T <br /> N CONTRACTOR AOORESS I CA LIC I CLASS <br /> � ,RI INSURES WORK.=4P. <br /> C I OTHER INFORMATION <br /> 0 I PHONE 4 <br /> R <br /> ' lIIl1lIlII!l111II1II11I11I1IIi � PHONE T <br /> iANK IO .� TANK SIZE CHEMICALS STCRED CURRENTLY/PRE'/ICUSLY I OATS UST INSTALL-D <br /> A <br /> 39- <br /> -,q- <br /> 39- <br /> 39- <br /> :9- <br /> 39- <br /> ? <br /> 9-39- <br /> :9-)`7- <br /> 1 � <br /> L APPRCVED APPRCVED WITH CCNDIT!CN(S? <br /> DISAPPROVE:) <br /> A (SEE ATTACHMENT WITH CO4017IONS) <br /> N PLAN .IEVIEdERS ldAME OAT- <br /> —,111111I11IIIIHIIIIIIIIIII II11111111111111111IIIIIIil111l11111i111111I1i11111 11111illi(IIIAlli11111111111I1i11l1lllilil111 <br /> i <br /> APPLICANT MUST PERFORM ALL WORK IN AC;ZDANCr 'dITH SAN :CACUIN COUNTY OROINANC`cS, STATE LASS, AND RULES ANO REfiULATIC.NS OF <br /> .AN .OACUIN COUNT' PUBLIC 4EALTH ScR`li G S. Cl-'NER OR L:CZNSEO AGENT'S SIGNATURE CERTi=IES THE FOLLOWING: "I CT:FY THAT IN <br /> rHE PcZc,CRMANCE OF 7HE '•.ORK FCR '»HICHi THIS ?ERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUC:i A 4ANNER ASTO 3E=ME <br /> SU8_cCT i0 XRKER'S ..OMPENSAT:CN !AUS OF CALIFORNIA." <br /> C -- _ <br /> 'HAT iN 7"-';-: ?QR=CR4ANCE OF THE »CRK .ORA�H ONTRAC70R'S ;ilR:NG^OR SUBCONTRACTING SIGNATURE __R7: HE rOLL-,NG: <br /> IC:i THIS PERMIT is ISSUED, 1 SHALL EMPLOY PERSONS _UE c_. "C :CRKE2'S <br /> `O4PEASA7:CN '.X.S OF _ALiFC <br /> APPLICANT'S SIGNATURE: /e 717Lc <br /> I <br /> i <br /> SP-LING INFORMATION: <br /> ^cicace .ne resecnsibla carry co be billad -or acditiera( P4S-c30 star- -:me excerded `,eycrd permit caymenc average :er :ank. If :he <br /> aarcy COS;Cnaty belay S di?rer?nC :nan :ne Per.'.mit acULicant, a.3. pricer a4 , ;h �— <br /> ^e willing ty signac _ arc data b ccs+. "/ ner a -arty nst ac e+l--;e .-ts 'escersibil :y ar <br /> carne <br /> `!ailing Address <br /> :ay Phone Nuns r ) <br /> 3 i gra cure <br /> E3 3-J033 <br /> i <br />