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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDEOO TANK RETROFIT, TANK LINING, OR PIPING*IR PERMIT <br /> f. <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT URITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE RELCN: <br /> _TANK REPAIR/RETROFIT __TANK LINING PIPING REPAIR <br /> EPA SITE 0 <br /> D /�I PROJECT CCNTAC & TELEPHONE 9 <br /> F FACILITY NAME C� PHONE <br /> A � o a- <br /> C ADDRESS 1 <br /> �a <br /> L CROSS STREET �fjn <br /> T ICVNER/CPERATCR II PHONE <br /> CCONTRACTOR NMPHO ". <br /> I <br /> C „ 7 <br /> V CONTRACTOR ADDRESS I CA LIC 7 /)�/b/r_ASS ,/I <br /> t ; L UV/tlP /`'/ f� <br /> 2 I INSURER <br /> A I LCCRK.C:.MP.T <br /> C i OTHER INFORMATION <br /> I r <br /> O I PHONE A <br /> R <br /> j <br /> II11111111111111]IlIll(lI11111 <br /> PHONE <br /> TANK IO T /TAS Silt CHggC LS STORED CURRENTLY/PREVICUSLY GATE UST INSTALLED <br /> 39- - v/ <br /> 39- <br /> A 39- <br /> � <br /> 1111111111111111IFTFUUTTRT III III fill IIIIIIIII I III IIFFFFII 11111[1111 <br /> I <br /> APP3C D APPROVED '.ITH CCNDIT!CN(S) OISAPPROVE7 <br /> CS"^ ATTACHMENT WITH C.^.NO1T,,CNS3 <br /> 11lllllll]1I1111lIIlIlI11 riilillllt IIllllll11111 <br /> Jill] <br /> 1111111111111111111111111 II1t11111111Ii1l11111111J11111fi11 11111111111 <br /> APPL!CANT MUST PERFORM ALL WORK IN AC`:.'RDANC_ WITH SAN iCACUIN CrIINTY CRDINANC_S STATE err iC <br /> SAN :CACU(N C�JNTY ?'13L!C HEALTH SERVIC=S. :HER CR r LAWS, AND RLt=S AND R_wLAT. NS OF,,, <br /> L:C_NSED AGENT S SiGNATLR. CSRTTF!ES THE =vLL.'ING: "! =T:FY THAT IN <br /> PeRc.CRMANC_ OF TRE :CRK FCR '»HICH THIS PERMIT IS !SSIJED, I SHALL NOT =1PLOY ANY PERSON !N SUCH MANNER AS TO Se^�_ME <br /> SU9.__' 70 .CRK_R'S C_MPSYSA7!CN LAWS CF CAL:FCRNIA." ^CNTRAC'CR'S HIR:NG CR SU9C:NTRACT:NG SiGNATL'R-c C_R'."._S THE FOLL..:N <br /> iHAT !N i:._ PERFCRMANC_ OF 'HE '+CRX :,OR :HICa T8I5 PER i5 ISSUED, SiiAL: _RPLOY PERSONS _^_ G: <br /> rMP=rfSAT.CN L.;'.S OF CAL!FCRN!A." ? R_�?1S SL6.�_. TO JCRK_R S ` <br /> AP?L:C:,N T'S SiGNATUR_: -. _ 9 <br /> 1 i L. :.� L � • i <br /> ,ILL:NG !NF:RMATICN: <br /> ndicat_ .ne rascarsibLe car-y :o =e hiLLe_ for additieraL P9S-_M0 staff -=.,.e exceeded `eycnd _er-sit _ayment :cverage _er ;ank. Ic n e <br /> :ar-� _es:era: beLou is dicferent ;::an ,::e :e:-sit aCC(.cant, a ;. or^^ <br /> er y Tuner, ;he ;ar^/ est ac acuL ;e .,is r_rcnsibili;y fcr <br /> .ne --y s:gnat.;re and date beLou. <br /> Name <br /> Mailing Address <br /> :ay Phone Nu=er ( ) <br /> i i gra cure <br /> �-'etcf <br /> SH ZZ-M33 <br /> Z <br />