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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone: (209 ) 458-3420 Fax: (209 ) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 100 DAYS. FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> Q TANK RETROFIT ❑ PIPING REPAIR/RETROFIT 'UDC REPAIR/RETROFIT 0 COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Emily Crain 918-371 -2380 <br /> A Phone # 209-477-5530 <br /> Facility Name ArcogmPm <br /> L Address 10715 Trinity Parkway, Stockton, Ca 95219 <br /> I Cross Street <br /> T <br /> Y Owner/Operator <br /> U Phone # .� <br /> C Contractor Name BZ Service Statlon' aintenance Inc. l Elite IV Phone # 918-3714380) 209 461 -6337 ' <br /> N <br /> Contractor Address pobox 933 W. Sac,CA/ 2535 Wigwam Dr. Stockto CA tic #433159 /1001331 Class B C-61 D40/A H AZ <br /> R Insurer SEE ATTACHED Work Comp <br /> i E ICC Technician's .Name see attached Expiration Date _ <br /> oIGC installer's Name see attached Expiration Date <br /> R _ <br /> w Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 pipMp sump, 91 leak detector, U00 V2,etc.) Installed <br /> T 87 25431 gasoline <br /> A 9111904 . gasoline <br /> I K -DSI ., _ X90 ` L <br /> In -� Approved Vf Approved with conditions El Disapproved <br /> L (Se , Attachment With Conditions) <br /> A Itp <br /> N Plan Reviewers Name � Date D � ?A <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATION$ OF SAN j <br /> JOAQUIN COUNTY: ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED. AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: ") 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 CALIFORNIAs" %r 0JJ ] <br /> Apptioanrssignature iL �r✓ Ii" TRIe v 1 t Date c ?a l <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 /> NAME Arminder Lada TITLE owner PHONE # 209477-5530 <br /> ADDRESS Same as above <br /> SIGNATURE <br /> EH230038 (revised 92-11-16) 2 <br />