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SAN JOAQUIN Environmental Health Department <br /> - COU NTY - <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 /> Li TANK RETROFIT ` OPIPING REPAIR/RETROFIT l�lGDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Robert Velasco/661 -250 -9300 <br /> A <br /> C Facility Name BP Arco AM /PM #2093 Phone # 661 -250-9300 for this projec <br /> � Address 3425 Tracy Blvd . , Tracy CA 95376 <br /> T Cross Street Clover Road <br /> Y Owner/OperatorBP Products North America Inc . Phone # 661 -250-9300 for this projec <br /> o Contractor Name Charles E . Thomas Company Inc . Phone # 661 -250-9300 for this projec <br /> T contractor Address 13701 Alma Avenue , Gardena CA 90249 CA Lic # 302015 Class A , B , C- 10 , C 1 <br /> A Insurer Republic Indemnity Company of California Work comp # 25532203 <br /> T ICC Technician 's Name Andre Garnier Expiration Date4/6/2023 <br /> R ICC Installer' s Name Mark Ford Expiration Date 3/24/2023 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (I . a 87 piping sump, 91 leak detector, UDC 112, etc ) Installed <br /> T UDC 1 /213/415/617/8 & related piping Existing to rema iWnleaded fuel Unk. <br /> A <br /> N <br /> K <br /> P ❑ Approved 0 Approved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions) <br /> N �qfjejPlan Reviewers Name Date zU L <br /> APPLICANT MUST PERFORM A2CRNIA. " <br /> ANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS , AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMPARTMENT . OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WHIS PERMIT IS ISSUED , I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LOFNIA. " CONTRACTOR 'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIESTHE FOLLOWING : "I CERTIFY <br /> THAT IN THE PERFORMANCE WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicanl'sSignature TilleAgent Date 1 / 16 /2023 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for acjoitional EHD staff time expended beyond permit payment coverage per <br /> tank . If the party designated below isflaPqQE <br /> ent than the permit applicant, e. g . property owner, the party must <br /> acknowledge this responsibility for the billsignature and date below. <br /> NAME A & S Engineering/ Rober Agent PHONE o 661 -250-9300 <br /> ADDRESS 28405 Sand Cany oad , Suite " B " , Canyon Country CA 91387 <br /> SIGNATURE DATE 1 / 16/2023 <br /> 2of6 <br />