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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 X PIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +----------------------- -----------------------------------------------------------------------------------------------+ <br /> I + EPA SITE #-- PROJECT CONTACT_&-TELEPHONE_#_Kathy-Smith 0310)323-6730 ext 267: <br /> P FACILITY NAME Arco-6020------------------------------------------------ PHONE #------(209j823-4715--- --? <br /> C ; ADDRESS 1711 Yosemite __Manteca,_Ca__953-6 _________________ <br /> ' I : ADDRESS <br /> ------------------ <br /> L : <br /> , <br /> L ; CROSS STREET Hi hwa 99--------------------------------- ---------------------------------' <br /> T ; OWNER/OPERATOR ' PHONE # ' <br /> _Y_+_________________________ BP West Coast Products LLC________--+_----_ ____(760 746 - 0030 <br /> - - - <br /> C ; CONTRACTOR NAME Charles E,Thomas Co. P # 310 323.6730 ext. 259; <br /> ' 0 ----------------------------- - - - - - - --------------------------------- - - - - <br /> N ; CONTRACTOR ADDRESS 13701 S. Alma Ave. Gardena, Ca. 90249; CA LIC # _302015 CLASS c10,C61ID40, Haz,A: <br /> T +--------------------------------------------------------------------------------- -------------------------------------------; <br /> R ; INSURER State Fund ; WORK.COMP.# 1 7660 8904 <br /> ------------------------------------ <br /> C ; OTHER INFORMATION <br /> ' T +------------------------------------------------------------------------------------+---------------------------------------' <br /> O ; PHONE # <br /> i <br /> PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK ID # TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> 39- 15,000 gallons 87 octane tank Unknown <br /> T ; 39- 15.000 gallons 89 octane tank Unknown <br /> A 39- 12.000 gallons 91 octane tank Unknown <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P ; <br /> L ; ' APPROVED C APPROVED WITH CONDITIONS) DISAPPROVED <br /> A ^f r,, (SEE ATTACHMENT WITH CONDITIONS) A <br /> N ; PLAN REVIEWERS NAME IN, 1`'v, DATE I Z� <br /> + <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: TITLE <br /> Permit!Agent DATE <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 Phone # <br /> Signature 0/� zm' <br /> T," <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />