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m <br />A <br />1. IiJhi p�'`I�Y.YWIy �.: �� �1. <br />• ! �1 P (} <br />I � <br />1 <br />t` SEP 16 1992 <br />ANYIi91NMTK NfAbTM MIYIi19T1 ENVIRONMENTAL HEALTH <br />PERMITISERVICES <br />AMONCATIQII I'M INIDEMWW RIM* TANK %9W KIMIT <br />APPLICATION FOR PERMANENT/TEMPAN V R49M 01 "ANOG"NT IN::IW W "ERRRIXNiI NAZARKo WAISTANCE STORAGE TANK <br />TH1s PERMIT EXPIRES fAQN T IIMPMQMAI� QATMq QR MOT,MIT1 tN AMY iW►W AREAI. 11[IQII:ATR PERMIT TYPE dELiAI: <br />Alr ...q..�► Z'MIA�i,ll IN P1,AGN <br />EPA $119 k_Q Z t '-?--I ?AMC' pMTN ' L 144FNO X� C� S <br />A ,t <br />F F o r. l l (T Y HANE 1 .r �.--q . _ — ho ` I+tia.L vu _ � /h e . PNOIIE L/%S -moi . S <br />A <br />C ADDRESS r ? <br />L CROSS STREET <br />i oWNER/OPERATOR <br />Y (Y' <br />C I CONTRACTOR NAME <br />0 <br />N CONTRACTOR ADPRESZ %7-4t> <br />K <br />INSURER '-v <br />t tAA <br />A <br />C IIREDISTRICT <br />i ---- <br />o IABURAiORY NAME <br />SAMPLING FIRM L� <br />i l l l l 1111 I TI1 KI pl 111111111 *�* <br />39- <br />39- <br />A <br />9 -39-A 39-� � <br />N 39- <br />g <br />9 g 39- <br />39- <br />39- <br />A <br />9-39- <br />IIIIffrllTfTTI1TTIT <br />►1 14 <br />PI <br />PLAN REVIEWERS NAME <br />Illlllllllllllltllll <br />APPLICANT MUST PERFORM L wm IN AG <br />SAN JOAQUIN COUNTY PURLIG NEALTN WAY <br />IML PERFORMANCE OF THE WORK FOR 1NIIC11 <br />sU3.lECT TO WORKER'si COW996ATION LAMS <br />=II CERTIFY THAT IN THE P90011 64 QE <br />LWPENSAT ION LANE QF CAMPRl1I 'C <br />APPLICANT$ SIGNATURES <br />1.11 zs U46 (ROV1614 7/19(919) <br />�>/-'t - I c S %b <br />PNC+NE <br />Eaz;._.. <br />—3T— CA 410 IS q/ <br />PERMIT it <br />CAIf T EQ GIRRENTLY/PREV'OUSLY DATE <br />'Yj WO <br />s <br />lisp 010 <br />flTlll�llriflill I Ii lu <br />IgyEp.� 1 �ITIoMTiI 9tiJ►PP�GVf99 <br />ITN �IT►QNR1 .' '� GATE <br />��IIIt111TmlYftmnr n l l I � I (III I <br />PITY SAM iWiM11M Gl>IMTr GRDINAW l, STATE LAWS. ANO RULES AND REGULATIGNS CI <br />11 LICEMRip AGBYTIR i1GNAT1IRE CERTIFIES THE fO1L0WIN64 "1 CERilfY INA! +N <br />R IT 1; IN1t1EY. 1 <br />11µ4 NOT EMPLQY ANY 1194WW IN SACH A MANNER AS Tu BECLM1. <br />T4AO>141T#• MIAINQ OR +IlYQMTRAr.TING $14NATt*f CE911F1ES THE 1u11...1:1f <br />lot W160 TMI1 110111 is I61m1 ! I;N*�L EMPLQX.Pf W16 W44ECT TO WUR1.EI0: <br />n r - <br />,I ,'• 1 . TITkQ, n GATE I <br />lop <br />b.1r Ta'i <br />77 <br />1 ��•f Hl •i I <br />