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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 9.5202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />C <br />Facility Name Arco AM/PM <br />Phone # 209 466-6633 <br />1 <br />L <br />Address 130 S Wilson Way Stockton 95205 <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator Lawrence Wright <br />Phone # 209 466-6633 <br />o <br />Contractor Name APEC <br />Phone # (209) 943-3000 <br />N <br />T <br />Contractor Address PO Box 55105 - Stockton, CA 95205 <br />CA Lic # 341375 Class A / B / C-10 <br />A <br />Insurer State Fund <br />Work Comp # 238-0005332 <br />C <br />T <br />ICC Technician's Name Gavin R Williams (8016288) <br />Expiration Date /6/12 <br />P 8 <br />o <br />R <br />ICC Installer's Name N/A <br />Expiration Date <br />P <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2. etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved "proved with conditions Disapproved <br />L <br />S e Attachment With Conditions) <br />A <br />N <br />Date Y� /l `t /ZO <br />Plan Reviewers Name <br />APPLICANT MUST PERFORM ALL WORK IN ACCORD N WITH AN JOAQUIN TY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />/ <br />- Authorized Agent 4/13/11 <br />Applicant's Signature — /�'L Title Date <br />BILLING INI-I I II <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME Carl Henderson TITLE Technician PHONE # (209) 467-7573 <br />ADDRESS PO Box 31325 - Stockton, CA 95215 <br />SIGNATURE <br />EH230038 (revised 02/20/09) <br />1 <br />4/13/11 <br />