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-� ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNOEi .,.,ID TANK RETROFIT, TANK LINING, OR PIPING PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM TH APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK REPAI RETROFIT TANK LINING PIPING REPAIR <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # N 1— <br /> F FACILITY NAME ARCO 414/PM PHONE # 209 474-9125 <br /> A <br /> C ADDRESS 3250 Gd. HAMMER LANE <br /> I <br /> L CROSS STREET KELLY DR. <br /> I <br /> T OWNER/OPERATOR JIM PARKINSON PHONE # <br /> Y <br /> C CONTRACTOR NAME ELITE IV CONTRACTORS PHONE # (209) 461-6337 <br /> 0 <br /> N CONTRACTOR ADDRESS 2736 TEEPEE DRIVE #C CA LIC # 660076 CLASS A,B ,HAZ , C-10 <br /> T <br /> R INSURER S .N. POTTER WORK.COMP.# 1312739-93 <br /> A <br /> C OTHER INFORMATION updating existing system (leak alert) <br /> T <br /> 0 PHCiiE T <br /> R <br /> PHONE # 1 <br /> I1111111111CIIlilIl1111i111111 <br /> TANK IO 9 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- owen cornipR 12000 Arco unl . ARRE <br /> T 39- ' <br /> A 39- Owen COrninge Arc6 sut r 9 me un1 . ' APPROX . v <br /> N 39- <br /> K 39- - GASOr•TN <br /> 39- <br /> 39- <br /> lill <br /> P <br /> L ROVED PP 0 T ONDITION(S) DISAPPROVED <br /> A (S A H CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 11111111111111111111111 ! 111111 I III I I I I I InhiminmhunninniniiInninnininnimi inI III I IIIA I rill11 1 1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. 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 <br /> SUBJECT TO WORKER'S CCMPENSATICN LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OFT E WORK WHIC THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: ` /G TITLE CLlY/� DATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br /> party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br /> the billing by ssiggnaturee and date below. <br /> Name <br /> Ma i t i ng Address_ ��cs,9 <br /> Day Phone Number <br /> Signature <br /> EM 23-0038 <br /> 1 <br />