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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3RD FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: _TANK RETROFIT PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +------------------------------------------------------------------------ ---------------------------------------+ -EPA SITE-#--- ----------------- -PROJECT_CONTACT-& TELEPHONE-#_Kathy Smith Q10) 323-6730 ext 267: - p F FACILITY NAME Arco 6080 _PHONE)# A +---------------- ------(209 983-9140 ------- C ; ADDRESS--------------------------- -85 E_Louise Ave.-___Lath rop- Ca:95330------------------------------ L ; CROSS STREET I +--------------------------------------- Interstate 5)-------------------------------------------------------------------' ; T ; OWNER/OPERATOR ' PHONE # ' ;-Y : BP_West Coast Products LLC _ +______ __ (760 746 - 0030 C CONTRACTOR NAME PHONE # 0 +---------------------------------Charles_E._Thomas Co. ------ 3.6730 ext. 259: N ; CONTRACTOR ADDRESS 13701 S. Alma Ave. Gardena, Ca. 90249: CA LIC # 302015 CLASS C10,C61040, Haz,A ' T +-------------------------------------------------------------------------------------------------------------------------- R , INSURER State Fund ; WORK_COMP_#______176608904 ' A '------------------------------------------------------------------------------------+---- - - - - - C OTHER INFORMATION O ; ; PHONE ' --------------------- HONE +---...................I'...... ----------------------------------------------------------- ------ ------------------- TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- 12,000 gallons 87 octane tank Unknown T 39- 12.000 gallons 89 octane tank Unknown A 39- 12,000 gallons 91 octane tank Unknown N 39- K 39- 39- 39- P L APPROVED APPROVED,WITH'CONDITIONS) , DISAPPROVED A ; SEE ATTACHMENT WITH CONDITIONS) �f N PLAN REVIEWERS NAME I`N(A DATE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: TITLE Permit.Agent DATE �Z s -------------------- --------------- --------------------------- BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name Address Phone# Signature !a EH230038 (revised 1/31/02) 1