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1 1 i PHONE 2 1 rt(lTrftir/l ■71f [ltltri7rlttrr rr ll 111 111 llllltllllll(111111111 TAXK TLD g T:-\_, SIZE AL 1 39- ! - CHEMICALS STORED CUForurLy/P¢y!/C;ISLY DX,—. UST D4SrALI.ED T I 19- 1 1 i .1 1 39- 1 1 X i 39- i i 39- 1 39- I j �Ii1I1111il11IIIII11II1)IIIII{11{I[II1I111{)llil{I1illllliti111{IIlllll111If1It11111111{1{1111i1t11111![Iltill11111I{1)111111i� i APPROVED ✓ APPROVED vITH ONDI'=0N(S) DISAPPROVED 1 -J i S-�{�1EEM �_AZTAC=£2%C :7Z2ll COXDiTIONS) ` 1 .r i ?LAM RE V Zc`.7E,"LS NAME � . A A/V /! �' / DATE --lJill] 11111111I1fill 11111111111111111111111)I1111 Illillllllllll!{Ililllllili1111111iIIlIi1ItII11I1ililllllf{11i11ti1II{Illlil 1P?LICANZ MI5–. 2ERFORH ALL WOR:C IN ACCCRDAVCT :::TTI SAN SOAQUZN COfM'Y O?FINANCES, STATE LAWS, .lN'J .2UL�S AND iEGULATZONS OF 1 .Sa.Y JOAQIIIN CDUNCY ?UBLZC KEAL:i SERVICES_ C:.1- OR LICENSED AGENI•S SIGNATURE C--xnFIES THE FOL:AvZNG- -1 C!j:2T: FY THAT IN ! 1 T1= PERFORMANCE Of TY£ PORK F ? :THZCH THIS ?=tiiZ2 iS ISSUED. Z S)iAl.2. NCT r'?1pLOy ANY P_RSON IN SZ�', A rpNNF3t AS -1-0 dECOrtE_ j SUBJECT TO WORi�Y•S COMPENS ZO_ LAWS OF CAL::-ORITIa CONSRACMR•S HIRT - OR SUBCONI2ACIZRG SIGNa:URE CE:YTZ FITS TRE FOLIAVZI`G- -•_ CERTIFY 'I'_:%+T ZV THE PEA RMA_ . OF THE WG.R-Z FOR WHICH THIS PERMF I5 a5SUED, I SHALL EMPLOY PERSONS SU3JECT 'O YURKER•S 1 C3MPr'NSATION -AWS OF CALIr RNIA I ///////// . _ :_7PL7CANT'S SIGNATURE: • TI0'Y�(,�. 1 B iLLING INFORMATION= I=ndicate the responsible party to be billed for additional PHS-EHD staff time expended bevond ae mit payment coverage per tan -k- If the party designated below is differ -^.t than. the pe_—It applicant, e-9- property owner, `ze party must acknowledge this responsibility for the billing -!.>v signature and date below_ h eS / oae number f `•� S .gnature ii�:11 23-0038 I • �1 � �) ,��. }�1%'w�lJ Y��fl/ J �1.�� 3" 1tC 6 t�t i�Lti vv� L �`n'► r �h� new g11►np s��r 2• AJ�VIJ A AWC-C, -6v- ail 3. 6j)&alt, i nc ptu i m b,% 9 (¢'03 1 APPLICtTION _C2 OKDERGROUN-3 'a.•tK RLIROFIT, OR PIPING 'REPAIR PERMIT r�3IS ?ERMIT EX?:IRIS 90 DAYS F RCM TKS APPROV;,_ Da-I'E-_ DO NOT 'URI:E IN .1I.^' SHADED ARIAS- I*TJICa:E PERMIT —PE BELOW - PIPING REPAIR EPA Srrs 3 ?ROJECT CONTACT i TELEP4CNE C t•(A`L �. j FACILITY.A ffAw PHONE? j —DREss z CROSS S REF'=- S , � -T I OWNER/OPERA OR e , PHONE a _ v , C CONTRACTOR . Y VIE / _ ( ?HONE 3 I` CONTRAC17OR ADD T j Gl LIC 3 7 ( Ci_ASS JV Rj INSURER I WORK -COMP -3 C j OTHER INFO-L--ATION - I T i PHONE 4 1 1 i PHONE 2 1 rt(lTrftir/l ■71f [ltltri7rlttrr rr ll 111 111 llllltllllll(111111111 TAXK TLD g T:-\_, SIZE AL 1 39- ! - CHEMICALS STORED CUForurLy/P¢y!/C;ISLY DX,—. UST D4SrALI.ED T I 19- 1 1 i .1 1 39- 1 1 X i 39- i i 39- 1 39- I j �Ii1I1111il11IIIII11II1)IIIII{11{I[II1I111{)llil{I1illllliti111{IIlllll111If1It11111111{1{1111i1t11111![Iltill11111I{1)111111i� i APPROVED ✓ APPROVED vITH ONDI'=0N(S) DISAPPROVED 1 -J i S-�{�1EEM �_AZTAC=£2%C :7Z2ll COXDiTIONS) ` 1 .r i ?LAM RE V Zc`.7E,"LS NAME � . A A/V /! �' / DATE --lJill] 11111111I1fill 11111111111111111111111)I1111 Illillllllllll!{Ililllllili1111111iIIlIi1ItII11I1ililllllf{11i11ti1II{Illlil 1P?LICANZ MI5–. 2ERFORH ALL WOR:C IN ACCCRDAVCT :::TTI SAN SOAQUZN COfM'Y O?FINANCES, STATE LAWS, .lN'J .2UL�S AND iEGULATZONS OF 1 .Sa.Y JOAQIIIN CDUNCY ?UBLZC KEAL:i SERVICES_ C:.1- OR LICENSED AGENI•S SIGNATURE C--xnFIES THE FOL:AvZNG- -1 C!j:2T: FY THAT IN ! 1 T1= PERFORMANCE Of TY£ PORK F ? :THZCH THIS ?=tiiZ2 iS ISSUED. Z S)iAl.2. NCT r'?1pLOy ANY P_RSON IN SZ�', A rpNNF3t AS -1-0 dECOrtE_ j SUBJECT TO WORi�Y•S COMPENS ZO_ LAWS OF CAL::-ORITIa CONSRACMR•S HIRT - OR SUBCONI2ACIZRG SIGNa:URE CE:YTZ FITS TRE FOLIAVZI`G- -•_ CERTIFY 'I'_:%+T ZV THE PEA RMA_ . OF THE WG.R-Z FOR WHICH THIS PERMF I5 a5SUED, I SHALL EMPLOY PERSONS SU3JECT 'O YURKER•S 1 C3MPr'NSATION -AWS OF CALIr RNIA I ///////// . _ :_7PL7CANT'S SIGNATURE: • TI0'Y�(,�. 1 B iLLING INFORMATION= I=ndicate the responsible party to be billed for additional PHS-EHD staff time expended bevond ae mit payment coverage per tan -k- If the party designated below is differ -^.t than. the pe_—It applicant, e-9- property owner, `ze party must acknowledge this responsibility for the billing -!.>v signature and date below_ h eS / oae number f `•� S .gnature ii�:11 23-0038 I • �1 � �) ,��. }�1%'w�lJ Y��fl/ J �1.�� 3" 1tC 6 t�t i�Lti vv� L �`n'► r �h� new g11►np s��r 2• AJ�VIJ A AWC-C, -6v- ail 3. 6j)&alt, i nc ptu i m b,% 9 (¢'03 1