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SCE#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 PE;;PFYPE BELOW: <br />0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Alexia Ini ds (425) 251-6222 <br />A <br />C <br />Facility Name ARCO Loc. No. 2133 <br />Phone # 209 478-5552 <br />I <br />L <br />Address 2908 Benjamin Holt Drive Stockton California 95207 <br />1 <br />T <br />Cross Street Plymouth Drive <br />Y <br />Owner/Operator BP West Coast Products, LLC. ; Scott Listar <br />Phone # (714) 670-5152 <br />C <br />O <br />Contractor Name Fillner Construction, Inc, <br />Phone# (916) 624-1985 <br />N <br />T <br />Contractor Address 4470 Yankee Hill Road, Suite 200 CA LIC# 177928 Class B A HAZ C10 <br />A <br />Insurer Travelers Property Casualty Co. <br />Work Comp # UB8239X433TIL11 <br />TICC <br />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 Chemicals Stored Current) Date UST <br />y <br />(i. e. 87 piping sump, 91 leak detector, UCC 1n, etc.) <br />Installed <br />#1 Existing Regular Unleaded <br />12K Gasoline 04/06/99 <br />T <br />A <br />#2 Existing Regular Unleaded <br />12K Gasoline 04/06/99 <br />N <br />K <br />#3 Existing Premium Unleaded <br />10K Gasoline 04/06/99 <br />P <br />Approved <br />U Approved with conditions U Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANGE <br />WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />OAQUIN <br />COUNTY, ENVIRONMENTAL HEALTHLTHISP <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 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 />RKER'S COMPENSATION LAWS OF OACTOR'S <br />HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: I CERTIFY <br />HAT IN THE PERFORMAN F THE RK <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />jAWIcwre,8Ign9Unk_ <br />i <br />Tnb �!P. - M�;-T nate Lg%V.�ar1 <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 />(,114} u -Iv -SLS co <br />EH230038 (revised <br />0 <br />