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A01 Environmental Health Department <br /> C 0 U N T Y <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 /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/ RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # C D Q 35 (P5 T72- Project Contact & Telephone # 5l O ) LA6q> - 10zP j 1 I< VL bqA4 MA <br /> C Facility Name MAIN STREET ARCO AM PM — 3SIli ►QTEd kt► Phone # l2oq 0, 25 (.I E4 <br /> IL for <br /> Address 11 (D0 S MA1tA ST REIET MA14TELA LA 9 5331 <br /> I Cross Street 1N \ u .STR\ INL 066 & <br /> T (510 4 (0 00 - 2 `ijl <br /> Y Owner/Oper-ator 1WLDEEP S�► MZmA ' � -If'� St� IR. � ►�'�'� Phone # <br /> C Contractor Name DIM�AON > PETPLOLEUM SE9WVfoES0 tNL. Phone # Cg25) " Io *- OZ03 <br /> O <br /> N <br /> T Contractor Address 619 A:� I N Ca CT ANT10 Ck-1, CAck4So4 CA Lic # 1 o O S y y Class A <br /> A Insurer SiCATE " MOEmNSAT1oN IIASuitLM.iC-E. Fv1.11> Work Comp # C1214 '1yq, . 19 <br /> T ICC Technician 's Name <br /> T G0 PrDli�fLUPG SA=W Cf1EZ Expiration Date �- d1}-12021 <br /> R ICC Installer' s Name G0 NDBW PE S kN CKEZ Expiration Date 1 04 20 '1'3 <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i .e. 87 piping sump, 91 leak detector, UDC 1 /2 , etc. ) Installed <br /> T %> 1 F I L. L. SUMP 2 0 Y< <b �- -r l a I <br /> A 6 F\ u , SU m P 12 1 PRooasu C ► � g � <br /> N <br /> K G \ F \ LL SUPAP l0 1V, q 1 PRnPos jVISSEL 1 q -1- <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> 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 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." ' ' 1 <br /> Applicant's Signature Title &'Ayw,1 Date 2 1112.02. <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant , e . g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME SSU L DEEP 5" M 4 TITLE O W IJ �F=-Pn� PHONE # \?.� � 6 0 9 — b I I �- <br /> 3AK5120 mftofir <br /> ADDRESS 00 S hSTKEL T M " w r=7. cA CA 9533 rT <br /> J <br /> SIGNATURE DATE 119r) 2- 1 <br /> 2 of 6 <br /> ill <br />