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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3RD 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 />EPA SITE # PROJECT CONTACT & TELEPHONE # Kathy Smith (310) 323-6730 ext 2671 <br />---------------------------------------------------------------per�++ <br />F FACILITY NAMEPHONE_21) -----------------------------------------------' _PHONE # 209 941-2694 ' <br />I ,ADDRESS 3212 N. Californias Stockton,_ Ca._95204 ________________________! <br />L I CROSS STREET Ply_mouth---------------------------------------------------------- <br />' I +-CROS-- ---------------------------------- ---------' <br />T I OWNER/OPERATOR ; PHONE # ' <br />;_Y_+_________ BP_West Coast Products LLC 760 746 - 0030 <br />--- -------------------- <br />C , -CONTRACTOR <br />--------- NAME Charles E. Thomas Co. ; PHONE_#_j310i_323-6730 ext._259; <br />N I CONTRACTOR ADDRESS 13701 S. Alma Ave. Gardena, Ca. 90249; CA LIC # 302015 CLASS C10, C61040, Haz, -k <br />------------ <br />R ; INSURER State Fund I WORK.COMP.# 176608904 <br />' A'----------------------------------------------------------------------------------a----------------------------------------� <br />C OTHER INFORMATION <br />' T +-----------------------------------------------------------------------------------+------------------------------------- <br />I O ; PHONE # <br />' R +------------------------------------------------------------+--------------------------------------; <br />PHONE # <br />---------------------------------------------------------------------------------------------- <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- 20,000 gallons 87 octane master tank Unknown <br />T 39- 10.000 aallons 87 octane gasoline slave Unknown <br />A 39- 12.000 gallons 91 octane gasoline tank Unknown <br />N 39- <br />K 39- <br />39- <br />39- <br />P <br />L ; APPROVED 'd APPROVED WITH CONDITION(S) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN RBVIEWERS NAME DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN 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 THIS PERMIT IS ISSUED, I SHALL 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 />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: �� v TITLE Permit Agent DATE Z l S� <br />+-----------------------------------------------------------------------------------------------------------------------------+ <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, the party must acknowledge this responsibility for the billing by signature and date below. <br />Name / Address <br />Signature v A* <br />EH230038 <br />(revised 1/31/02) <br />Phone # <br />