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ENVIRONMENTAL <br />HEALTH DEPARTMENT BCE #13418 <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 RETROFIT OR PIPING REP PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW: <br />L_'TANK RETROFIT _'PIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT ✓'COLD,sART/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # M. Alexia igues / (425) 251-6222 <br />A <br />C <br />Facility Name ARCO Facility No. 2093 <br />Phone (209) 334-3678 <br />I <br />L <br />Address 3425 Tracy Boulevard, Tracy, <br />CA 95376 <br />TCross <br />Street W. Clover Street <br />Y <br />Owner/Operator BP West Coast Products LLC <br />Phone# (510) 432-8397 <br />C <br />Contractor Name <br />Phone # <br />O <br />TContractor <br />Address <br />A Lic # Class <br />AInsurer <br />Work Comp # <br />TICC <br />Technician's i I ation Number <br />Expiration Date <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Date UST Installed <br />Currently/Previously <br />T <br />A <br />N <br />K <br />P <br />r__Approved <br />_i Approved with conditions ;._;Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date <br />APPLICANT <br />MUST PERFORM A WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRON NTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE <br />OF TH ORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATI LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />IN THE PERFORM CE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signatur <br />Title Date <br />BILLING INFORMATION: <br />/EBarghausen <br />sponsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />gnated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />or the billing by signature and date below. <br />Alexia Inigues <br />Consulting Engineers, Inc. TITLE Project Planner PHONE # (425) 251-6222 <br />ADDRESS 18215 - 72nd Avenue South, Kent, WA 9SC32 <br />SIGNATURE <br />M. Alexia Inigues <br />EH230038 (revised 12/31/07) <br />