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0 0 5 (Z N qs z <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD 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 #_ - __ ___ -- _ --I PROJECT CONTACT & TELEPHONE # Smith Kathy( -310, 323-6730_ext_267 <br /> +------ -- <br /> F ; FACILITY NAME <br /> Arco 2133 ; PHONE # ((29 <br /> _0__j 478-5522 <br /> 1_ _ <br /> C ; ADDRESS 2908 Benjamin Holt Drive Stockton, Ca_ 95207 <br /> , <br /> L CROSS STREET <br /> ----------------------------PIymOUth--------------------------------------------------------------- <br /> I +_CROS________ <br /> T ; OWNER/OPERATOR ; PHONE # <br /> ;_Y : BP West Coast Products LLC +-_-__----_ (760)_746_-_0030 <br /> C ; CONTRACTOR NAME Charles E. Thomas Co. PHONE #_ 31.0) 3.23-6730 ext. 259 <br /> O +---------------------------------------------- ------------------------------ ------- - -- - <br /> 13701 S. Alma Ave. Gardena, Ca. 90249 302015 � CLASS C10,061040, Haz,A: <br /> N CONTRACTOR ADDRESS CA LIC # <br /> T +___________________________________________________________________________________________________________________ <br /> R I INSURER State Fund ; WORK_ -- _ _COMP.# 176608904 <br /> A <br /> C ; OTHER INFORMATION <br /> T +------------------------------------------- ---------------------------+----------------------------------------; <br /> O , , PHONE # <br /> PHONE # <br /> +--- ------------------------------ ------------ <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 12,000 gallons 87 octane master tank Unknown <br /> T 39- 12.000 oallons 87 octane gasoline slave Unknown <br /> A 39- 10,000 gallons 91 octane gasoline tank unknown <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPR VED APPIA.,ED WITH CONDITION(S DISAPPROVED <br /> A E ATT ENT WITH CONDITIONS) L b <br /> N PLAN REVIEWERS NAME DATE <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 /> APPLICANT'S SIGNATURE: TITLE Permit Agent DATE <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 /> 4 <br /> Signature <br /> E 8 <br /> (revised <br /> 1/31/02) <br /> 1 <br />