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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3a0 FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT PIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> }_____________________ ________________________________________ ______________________________________________________________+ <br /> 1 EPA SITE # - -- _ PROJECT CONTACT a TELEPHONE # Kathy Smith(310) 323-6730 ext 267: <br /> }_______________ <br /> P 1 FACILITY NAME Arco 76OOPHONE # <br /> A } (20_9_ _4 <br /> 65-5359 <br /> C <br /> ADDRESS-------------- - 125.0__N_Wilson_Way--- --S------ --- C_a_95202--------------------------- <br /> ! <br /> L 1 CROSS STREET Harding_ <br /> I +______________________ __________________ <br /> T IOWNER/OPERATOR PpONE q <br /> : Y-;- ----------------------- <br /> BP Coast_Products_LLC----------;____--------760 746 - 0030 <br /> C I CONTRACTOR NAME PHONE #_j_ - -2 r <br /> D ------------------------ Charles E_Thomas Co--------- ------- 310 323-6730 ext_259; <br /> N I CONTRACTOR ADDRESS 13701 S.Alma Ave. Gardena, Ca. 902491 CR LIC # 302015 1 CLASS C10,C61/040, Haz,A 1 <br /> T } _______________________________________________________ <br /> 176608904 <br /> I R I INSURER State Fund ' WORX'C�'# , <br /> : C OTHER INFORMATION <br /> r , <br /> O 1 I PHONE It <br /> -----------------------------------------------------------------------------------------------------------------------------, <br /> PHONE # <br /> +___j::L'I111;1;111111111 r, r.,r ______________________________________________________________________________________________ <br /> TANK ID # 1f1.'I„r11; TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED <br /> 1 39- 15.000 gallons 87 octane tank Unknown <br /> 1 T 1 39- 12,000 aellons 89 octane tank Unknown <br /> 1 A i 39- 12.000 gallons 91 octane tank Unknown <br /> 1 N I 39- <br /> 1 K 39- <br /> 39- <br /> 39- <br /> }___ rrr,r ir:r:r:rrrrrrrrrrr,r,r,rrrrrrrrrrrrrr r rrrrrrrrr,r,rr,. ,rrrrrrrrrrrrrr,r , r,rrrrrrrrrrrrr,rr rr <br /> P <br /> i N PLAN REVIEWERS NAME IIIIIIII IIIIrrrrr DISAPPROVED ; <br /> A r r rr E11A1T ) I <br /> 11" AGEMENT WITH CONDITIONS DATE 1 <br /> APPR ED APPROVED WITH CONDITION(S) <br /> +-- rrrrrrrrr irrrrrrrrrrrrriri.rirrrrrrrr rr rrrrrrrrr O„rrrrrrr <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAM JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH MIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORIDHZ'S COMPENSATION LAWS OF CALIFORNIA." ' <br /> 1 APPLICANT'S SIGNATURE: TITLE Permit Agent DATE zo//�J�( �; <br /> T <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, thel party/must acknowledge this responsibility for the billing by signature and date bellow. <br /> Name Address 4. Phone# 1��/2�G-Ssjy <br /> Signature �A L �es+a� Cir, 902¢9 <br /> EH230038 <br /> (revised 1/31/02) <br />