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9255517899 ' Line 1 0" ''.29 p.m. 11-04-2010 3/13 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> Gd REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACTJAMAL KABARITI PHONE#209.983.9144 <br /> FACILITY NAME BP ARCO#6080 PHONE#209.983.9144 <br /> ADDRESS85 E LOUISE AVE, LATHROP, CA 95330 <br /> CROSS STREET INTERSTATE-5 <br /> OWNER OPERATOR BP WEST COAST PRODUCTS, LLC PHONE#714.670.3058 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME G ETTLER-RYAN INC. I PHONE#925.551.7555 <br /> CONTRACTOR ADDRESS 6747 SIERRA CT. #J CA LIC#220793 CLASS A,B,C10,C5, <br /> INSURER TRAVELERS PROPERTY CO. WORKERcoMP#DTJUB78P41510 <br /> FIRE DISTRICT LATH ROP/MATECA FIRE PERMIT#10-00337 <br /> LABORATORY NAME CAL SCIENCE ENV LABS COUNTYORANGE PHONE#714.895.5494 <br /> SAMPLING FIRM STANTEC CONSULTING PHONE#9 16,861,0400 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAS DATE INSTALLED <br /> 39- v 12,000 REGULAR UNLEADED 10/1984 <br /> 39-.-L,.l L Uo 12,000 MIDGRADE UNLEADED 10/1984 <br /> 39- 12,000 PREMIUM UNLEADED 10/1984 <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COMPE ATION SOF CALIFORNIA." <br /> PROJECT MANAGER 11!0412010 <br /> APPLICANT'S SIGNATURE TITLE DATE <br /> ❑ APPROVED L(SEE <br /> ROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> NDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME !vel tn� DATE 1 I I L' <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE:SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046 (Revised 07/22/10) 3 <br />