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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton, California 95202 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# CAL 000 2 804 9 I Project Contact&Telephone# MICHAEL ARMOUR — —6668 <br /> C Facility Name CONOCOPHILLIPS FACILITY Phone# 0-473-73 <br /> I <br /> L Address 2701 W. MARCH LANE STOCKTON CA 95219 <br /> TCross Street I-5 <br /> Y Owner/Operator DARREN EPPLER Phone# <br /> C Contractor Name ARMOUR PETROLEUM SERVICE & EQUIP. CORP Phone#707-437-6668 <br /> 0 <br /> T Contractor Address PO Box 507 VACAVILLE CA — CA Lic# Class <br /> A Insurer STATE FUND Work Comp#0000728-2006 <br /> cICC Technician's Certification Number 5264326—UT Expiration Date <br /> T 07-07-07 <br /> R ICC Installer's Certification Number 5264326—U1 Expiration Date 04-05-09 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> t <br /> 15 154- REL UL AR UNLEADED Or/o►/ 95 <br /> At515y PREMIIUM o�/ot195 <br /> K 3 1.105Z DIESEL of/ol/ q5 <br /> P ❑Approved rC?Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name Date ZS <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.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 SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature 1 u`oL , a'VNQ Title H U wi st Date b ( 5 /0-7 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. p <br /> NAME 4lWL/ -TITLE PHONE#z`��� <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br /> 1 <br />