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t two BCE #13380 <br /> ENVIRONMINTALHEALTH <br /> SAN JOAUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ✓TANK RETROFIT OPIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT XCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Alexia Inigues 425-251-6222 <br /> A <br /> C Facility Name ARCO Loc. No. 2133 Phone# 209-478-5552 <br /> I <br /> L Address 2908 Benjamin Holt Drive, Stockton, CA 95207 <br /> TCross Street <br /> Y Owner/Operator BP West Coast Products LLC Phone# 510-432-8397 <br /> C Contractor Name out to bid Phone# <br /> 0 <br /> N Contractor Address <br /> T CA Lic# Class <br /> R Insurer <br /> A Work Comp# <br /> cICC Technician's Certification Number <br /> T Expiration Date <br /> 0ICC Installer's Certification Number <br /> R 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 ElApproved pproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name &2Date 162 IV" <br /> APPLICANT MUST PERFORM ALL WO 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,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> LConsultant for Mark Murgash <br /> Applicants Signature �"" Title Project Planner Date 3/13/2008 <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 /> NAME Barghausen Consulting Engineers TITLE Alexia Inigues PHONE# 425-251-6222 <br /> Project Planner <br /> ADDRESS 18215 72nd Avenue South, Kent, WA 98032 <br /> SIGNATURE <br /> EH230038(revised 12/31/07) F <br /> 1 <br />