Laserfiche WebLink
BCE#13380 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERM PE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT VCOLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Alexia Ini dS (425) 251-6222 <br />C <br />Facility NamePhone <br />ARCO LOC. No. 2133 <br /># 209) 478-5552 <br />1 <br />L <br />Address 2908 Benjamin Holt Drive Stockton California 95207 <br />I <br />T <br />Cross Street P1 outh Drive <br />Y <br />Owner/Operator Bp West Coast Products, LLC.; Scott Listar Phone# (714) 670-5152 <br />c <br />Contractor Name Fillner Construction, Inc. Phone# (916) 624-1985 <br />0 <br />N <br />Contractor Address 4470 Yankee Hill Road, Suite 200 CALIc# 177928 Class A HAZ C10 <br />T <br />R <br />Insurer Travelers Property Casualty Co. <br />Work Comp# UBB239X433TIL11 <br />A <br />C <br />r <br />ICC Technician's Name Steven H. <br />Richardson <br />Expiration Date April 23, 2012 <br />O <br />R <br />ICC Installer's Name Steven H. <br />Richardson <br />Expiration Date December 7, 2011 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently Date UST <br />(i e. 87 piping sump, 91 leak detector, UDC 1/2, etc ) <br />Installed <br />#1 Existing Regular Unleaded <br />12K <br />Gasoline 04/06/99 <br />T <br />A <br />#2 Existing Regular Unleaded <br />12K <br />Gasoline 04/06/99 <br />N <br />K <br />#3 Existing Premium Unleaded <br />10K <br />Gasoline 04/06/99 <br />P <br />Approved <br />M Approved with conditions U Disapproved <br />L <br />(Pee Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date17 <br />APPLICANT MUST PERFORM ALL WORK ACZWHITHIS <br />H SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY. ENVIRONMENTAL HEALTHOWNER <br />OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICS <br />ISSUED, i SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF OACTOR'S <br />HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN <br />THE PERFORM=THE <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applica0aSipnabue <br />Title VP, iMr Dote IL"111 <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 />ADDRESS ` <br />SIGNATURE <br />EH230038 (revised <br />lf-Agff k1l i"it• PHONE # <br />04q rosp Yt- OPS. <br />0► <br />&1.29//i <br />