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.Loi riai2U6.3 nib: ly 2by4683433 FaTH IrLULIP FAut uj <br /> San Joaquin County <br /> Environmental Health Department <br /> 304 E Weber, T4 Floor <br /> Stockton, CA 95202 <br /> AppllcaEon for Underground Tank Retrofit,or ptpinp repair perp* <br /> This pernit expires 90 days from the approval date. Do not write in any shaded areas. Indicate permit type bebW: <br /> W-�—Tank RetrofitUnder Dispenser Containment Repair/Permit _.-. <br /> EPA SRF-# I Project Contact&Telephone# Lon Freshour (916)858-1090 <br /> FACILITY NAME ARCO 6080 Phone#(209)983-9140 <br /> ADDRESS 65 E Louise Ave <br /> CROSS STREET I4 Phone#(209)649-3835 <br /> OWNER/OPERATOR SP West Coast Products,LLC <br /> CONTRACTOR NAME Tait Environmental Systems Phone# <br /> CONTRACTOR ADDRF_SS 3283 Luyung Or I CA LIC#588098 W rk Comp#009 000018502 <br /> INSURER Brakke Schafnitz <br /> OTHER INFORMATION Phone# <br /> Phone# <br /> Tank ID# Tank Size Chernical Stored Currently I Previously Date UST Installed _- <br /> -- ._. 2� Gasoline <br /> 39. t, <br /> 39- <br /> 39- i. <br /> 39- <br /> 39. <br /> Disa �-- -- <br /> Approved roved with Gondlfion s) pproved <br /> /O <br /> Plan Reviewer's Name <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES <br /> AND REGULATIONS OF SAN JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S <br /> SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS <br /> ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSEUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.' <br /> APPLICANT'6 SIGNATURE: <br /> TITL Ila r DATE 10IAID3 <br /> Billing Information: r: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. <br /> If the party designated below is different that the permit applicant, e.g. property owner, the party must acknowledge this <br /> responslbility for the billing by signature and date below. <br /> Name est oast Pdu—ct LC Address 4 Ce Pointe Dr a P lma CA 90 23 Phone# 209 6 -3335 <br /> Signature T1,f f11�� <br /> EH230038 <br /> (revised 1/31/02) <br /> ti <br />