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SAN JOAQUIN Environmental Health Department <br /> - - COUNTY - <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATF . INDICATE PERMIT TYPE BELOW: <br /> El TANK RETROFIT `B PIPING REPAIRIRETROFIT b'CJDC REPAIRIRETROFIT ❑ COLD START/EVR 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 /> I 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 Al 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 /213/4 , 5/617/8 & related piping Existing to remMiMnleaded fuel Unk . <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions) <br /> N Plan Reviewers Name Date LU <br /> APPLICANT MUST PERFORM A2CL <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 WTHIS 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 CERTIFIES THE 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 /> Applicant's Signature Till. Agent Dale 1 / 16/2023 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for adoitional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is diff ent than the permit applicant, e. g . property owner, the party must <br /> acknowledge this responsibility for the billin y signature and date below. <br /> NAME A & S Eng ineering/Rober lagRE Agent PHONE # 661 -250-9300 <br /> ADDRESS 28405 Sand Canyw oad , Suite " B " , Canyon Country CA 91387 <br /> SIGNATURE DATE 1 / 16/2023 <br /> 2of6 <br />