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15: b3 2094683433 FIFTH FLS PAGE 62 <br />L <br />San Joaquin County <br />Environmental Health Department <br />304 E Weber, :3n4 Floor <br />Stockton, CA' 95202 <br />ApplicdUon for Underground Tank 1196K or piping top* perrmi <br />This pemdt expires 90 days hm the approval dais. Do not write in any shaded anus. Indicate perrrdt We below: <br />_Tank Retrofit Piping Repair / Retrofit _ Under Dispenser Containment Repair /Permit <br />EPA SITE .� I; Project Contact & Telephone # Lorl Freshour (916) 858-1090 <br />FACILITY NAME ARCO 6347 Phone # (209) 830.8142 <br />ADDRESS 2430 Joe Pomp Pkwy <br />CROSS STREET Grant Line <br />OWNER / OPERATOR BP West Coast Products, LLC Phone # (209) 649-3335 <br />CONTRACTOR ADDRESS 3288 Luyung Or <br />INSURER Brakke Sd-k*ltz <br />OTHER INFORMATION <br />39- <br />39. <br />39- - <br />39 <br />3s - <br />Plan Revieewees Name <br />I CA LIC # 588098 <br />Class C10 B A ASB HAZ H1C <br />Work Comp # 092000018502 <br />Phone 0 (916) 8561090 <br />Phone # <br />APPLICANT MUST PERFORM ALL WORK 1N ACCORDANCE WITH 0 JOAQUIN COUNTY ORDINANCES, STATE LAWS, ANA RULES <br />AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS <br />SIGNATURE CERTIFIES THE FOLLOWING: 01 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS <br />ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA ° CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSEUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />^naA15OA1QAT1^k1 I A\AM MM PA! IM^Mkl1A 11 <br />APPLICANT'S SIGNATURE: T om r aAT Qs rD <br />Billing Information: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. <br />If the party designated below is different that the permit applicant, e.g, property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below, <br />Name JP West Coast Prog& LLC Address 4 CR&E Pointe Dr, Le,ftma CA 90623 Phone# (209, ,1335 <br />Signature 4 <br />EH230038 <br />(revised 1/31/02) <br />