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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT X PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +---------------- ---- --------------- ---------------------- -------------------------------+--+ <br /> -EPA SITE-#--------------------------- <br /> _ PROJECT _CONTACT &-TELEPHONE_#_Kathy Smith (310)323-6730 ext 267: <br /> F , FACILITY NAME-------- ------------------------------------------------------; PHONE # , <br /> A +-------- ------Arco_6313-------- (2099825-6784------' <br /> C 1 ADDRESS 1100 S._Main_St, Manteca,Ca. 95337 _ ' <br /> ' I -------------------------------- - <br /> L ; CROSS STREET <br /> I +-------------------------------------------nd ustrial---------- <br /> T ; OWNER/OPERATOR ; PHONE # ' <br /> :-Y ; ____ BP West Coast Products LLC_ _ 760 746 - 0030 <br /> C ; CONTRACTOR NAME Charles E. Thomas Co. ; PHONE # 310`) 323-6730 ext. 259: <br /> O +- - -------------------------------------------------------`------------------------; <br /> --------------- - - <br /> N ; CONTRACTOR ADDRESS 13701 S. Alma Ave. Gardena, Ca. 90249; CA LIC # 302015 CLASS CIO,C61/1340, Haz,A; <br /> T +-----------------------------------------------------------------------------------------------------------------------------' <br /> R ; INSURER State Fund ; WORK_COMP.# <br /> A ;------------------------------------------------- - --------------------------------+------------------176608904---- <br /> C ; OTHER INFORMATION <br /> ' T +------------------------------------------------------------------------------------+----------------------------------------; <br /> 0 PHONE # <br /> PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> 39- 20,000 gallons 87 octane tank Unknown <br /> T 1 39- 12.000 gallons 89 octane tank Unknown <br /> A ; 39- 10.000 gallons 91 octane tank Unknown <br /> N ; 39- <br /> K ; 39- <br /> 39- <br /> 39- <br /> + L 1111„"1"t'11' "t1I1"'1";APPROVED <br /> %11; IAPPROVED'WITH'CONDITION,(S) DISAPPROVED <br /> ;1'I"""'t"""1""'11" <br /> A N G (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME W' tV DATE L V <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> � q <br /> APPLICANT'S SIGNATURE: TITLE Permit Agent DATE <br /> +----------------------- -------jor----------------__..----------------------------- ---+ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Address Phone # <br /> Signature a141 <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />