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• <br /> ENVIRONMENTAL HEALTH DEPARTMENT BCE 13448 <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, 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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT WICOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# M. Alexia Inigues / (425) 251-6222 <br /> A <br /> C Facility Name ARCO Facility No. 5450 Phone# (209) 334-3678 <br /> 1 Address 1617 West Fremont, Stockton, CA 95203 <br /> L <br /> TCross Street N/A (off 1-5) <br /> Y Owner/Operator BP West Coast Products, LLC Phone# (510) 432-8397 <br /> C Contractor Name �� (�(� b�ZU }..� Phone# 6 62-C-1— 2T <br /> N <br /> T Contractor Address i4K-7V CA Lic# I7 Z q Class A J <br /> A Insurer Work Comp#LAX,2 42 21,5- <br /> C <br /> ICC Technician's Certi i a i m r Lj Expiration Date <br /> RICC Installer's Certifica' Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> 107 <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 Title Date <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. <br /> M. Alexia Inigues <br /> NAME Barghausen Consulting Engineers, Inc. TITLE Project Planner PHONE# (425) 251-6222 <br /> ADDRESS 18215 - 72nd Avenue South, Kent, WA 98032 <br /> SIGNATURE i <br /> EH230038(revised 12/31/07) <br /> 1 <br />