COMPLIANCE INFO_2002-2006 - Laserfiche WebLink

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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 X PIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +------- ----------------------------------------------------------------------------------------------------+ I + EPA SITE #_ _ _ _ : PROJECT CONTACT & TELEPHONE #-Kathy Smith (31 O) 323-6730-ext 2V267:7� F FACILITY NAME------ _Arco-2093-------------------------------------------------------------- , PHONE # 209 835-1605 I , ADDRESS 3425 N._Tracy-Blvd,,_Tracy,_Ca__95376 L CROSS STREET Highway_205------------------------------------------------------------------' I +-CROS---TREE------------------------- T OWNER/OPERATOR PHONE # !_Y_+ ______________BP_West Coast-Products_LLC-___-____ + - 760 746 - 0030 I C CONTRACTOR NAME Charles E. Thomas Co. -PHONE-# X310) 323-6730 ext. 259: N I CONTRACTOR ADDRESS 13701 S. Alma Ave. Gardena, Ca. 90249 CA LIC # 302015 CLASS C10,C61 040, Haz,A lT +--------------------- ------------------------------------------- R INSURER SFd WORK.COMP.# --------------------------------------- tate A tat - un --un --------------------------+- 176608904 C OTHER INFORMATION O , PHONE # PHONE # +-- ----------------------------------------------------------------------------- TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED , 39- 10,000 gallons 91 octane gasoline Unknown T 1 39- i 10.000 gallons 87 octane gasoline master tank Unknown A 39- 10.000 gallons 87 octane gasoline slave tank Unknown N 39- 10.000 gallons 87 octane gasoline siphon tank Unknown K 39- 39- 39- L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED AME , p)�� (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS,NDATE 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 CALIFORN 1 APPLICANT'S SIGNATURE: TITLE Permit Agent DATE , +----------------------- --------------- --- -------------------------- 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 EH230038 (revised 1/31/02) 1