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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : (209) 468 - 3420 Fax : (209 ) 468 -3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE , INDICATE PERMIT TYPE BELOW. <br /> D TANK RETROFIT D PIPING REPAIRIRETROFIT XUDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site # i Project Contact & Telephone # <br /> C Facility Name Arco AmPm —� Phone # 209- 224- 8925 <br /> I Address 900 S Cherokee Lane , Lodi , CA <br /> Cross Street <br /> T <br /> Y ownerloperator KPMC Management Inc Phone # 209"224- 8926 <br /> cContractor Name BZ Service Station Maintenance / MVP Phone # <br /> o _ _ <br /> N Contractor Address PO Box 933 , WSac I PO Box 281 , Folsom CA Lic vi 433159 / 768938 Class B c-61 Dau A B tlaz <br /> R Insurer see attached Work Comp # <br /> A <br /> c <br /> T ICC Technician's Name see attached Expiration Date <br /> - --- <br /> o ICC Installer' Ne Expiration Date <br /> R Installer's <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i .e. 87 piping sum, 81 leak detector. UDC 112, aic. ) Installed <br /> T DSL only on dispenser 11112 DSL. <br /> A <br /> N — -- - <br /> K DSL direct bury bucket and drop tube DSL <br /> P _ Approved Approved with conditions 1 . Disapproved <br /> L IS tachment With Conditions ) <br /> A �N Plan Reviewers Name Date <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 710 <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CO TRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE Of-, THEW K FOR tJ�Hieyl/f`HIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature� _� Title � 1JlI /) Date.-�_ <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional FHD 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 KPMC Management Inc TITLE Owner PHONE # 209"224» 8925 <br /> ADDRESS _900 S Cherokee Lane , Lodi , CA <br /> XSIGNATURE �' .�. .__ .__ DATE__ <br /> EH230038 (revised 12- 11 - 15) 2 <br />