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BCE#13455 <br /> ENVIRONMENTAL HEALTH DEPAR _ T�//-Ei� <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 N� <br /> Telephone: (209) 468-3420 Fat: (209) 468-3433 ENVIRGiv1'Ji SSI�FFI MEAL�H <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPIW64& � "Es <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑✓COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Alexia Inigues / (425) 251-6222 <br /> A <br /> C Facility Name ARCO Fac. No. 6020 Phone# (209) 823-4715 <br /> 1L Address 1711 E. Yosemite, Manteca, CA 95336 <br /> 1 Cross Street Hwy. 99/Yosemite <br /> T <br /> Y Owner/Operator gp West Coast Products LLC Phone# (510) 432-8397 <br /> Q Contractor Name <br /> 0 Fillner Construction Phone# (916) 624-1985 <br /> N Contractor Address 4470 Yankee Hill Road, Suite 200 CA LiC# 177928 Class <br /> T <br /> R <br /> A Insurer American Guarantee and Liability Insurance Cc. Work Comp# WC 399295904 <br /> cICC Technician's Certification Number See attached <br /> T Expiration Date <br /> RICC Installer's Certification Number see attached Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved ❑Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature % // Title E—ironm-- comp- ,�.<._ >«_., isc Date / L <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> M. Alexia Inigues <br /> NAME Barghausen Consulting Engineers, Inc. TITLE Project Planner PHONE# (425) 251-6222 <br /> ADDRESS 18215 - 72nd Avenue South, Kent, WA 98032 <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 13455.001.pdf <br />