COMPLIANCE INFO_2003-2005 - Laserfiche WebLink

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• • San Joaquin County Environmental Health Department 304 E Weber, 3`d 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 / Permit _................--........................_..............._....._..............................................................................................................................p.......9................................................._.................................................................... EPA SITE # I Project Contact & Telephone # Lori Freshour (916) 858-1090 FACILITY NAME ARCO 6347 Phone # (209) 830-8142 ADDRESS 2430 Joe Pombo Pkwy CROSS STREET Grant Line OWNER / OPERATOR BP West Coast Products, LLC Phone # (209) 649-3335 ......................................................................................................................................................................................................................._..._.....__. CONTRACTOR NAME Tait Environmental Systems Phone # CONTRACTOR ADDRESS 3283 Luyung Dr I CA LIC # 588098 Class C10 B A ASB HAZ H1 C INSURER Brakke Schafnitz Work Comp # 092000018502 OTHER INFORMATION Phone # (916) 858-1090 i Phone # i I I Tank ID # Tank Size Chemical Stored Currently / Previously Date UST Installed I .................................................................................................. i _ ... ............... _...._......................................................................................................................................................................... ......................_._............_....._._................._....__..........._..:..._........ ...__......__...._.._...__..._.... _.......... _.....................................................,......... 39- 87 20000 Gasoline 39- 39- 39- 39- 39- 39- . 939- 39-39-39-39- Approved with Condition( Disapproved Plan Reviewer's Name i 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 i 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 ISSEUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." j ..................................................._.._......................._.........................._........ --.__...__.... .................... ............................................. ................................................................................ ..._.............................._........_........._........_.._............................._.....__..._................................................................................ APPLICANT'S SIGNATURE: TITLE Compliance Mqr DATE �� d I I..................................................................... _...................... .......................... .._.._.._................ . ................. .. ........................ _............................................ ........_..................... ..................._...................._........................................................................................_........................... 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 that the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name BP West Coast Product, LLC Address_4 Center Pointe Dr, La Palma CA 90623_ Phone# (209) 649-3335 Signaturedk�,P�i6G� EH230038 (revised 1/31/02)