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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3ao FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE.DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: _TANK RETROFIT XPIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ---------------------------------------------------------------------------------------------- ----------------- --- EPA SITE # 1 PROJECT CONTACT & TELEPHONE # David Camile 510 245 5219 i F i FACILITY NAME Conoco Phillips Site #30877 ------------------------------------------------------- _Y_PHONE-# 209 823 7676_________________ A I C 1 r - - y - i I I ADDRESS 1700 Yosemite Ave, Manteca CA 95336 L --------------------------------------------------------------------------------------------------------------------------------------------------------------------- I I 1 CROSS STREET Highway 99 T Y OWNER/OPERATOR Conoco Phillips ; PI-IONS # 510 295 5219 ------------- ------i -------------------------------- ------------------------------------------------------------------------------------------------------`-------------------------------------------------------------' 1 CONTRACTOR NAME Triangle Environmental, Inc PHONE # 818 840 7020 C 0 ----------- - --- --- --- - - - - -------------------- ---------------------------------- i i CONTRACTOR ADDRESS 2525 W. Burbank Blvd, Burbank CA 91505 CA LIC # 673971- 1 CLSS N --------------------------------------------------------------------------------------- - I ------------------- I INSURER State Fund WORK.COMP.# 1555802--04 R i h---------- -------------------- - - - I A OTHER INFORMATION + I C T 1 PHONE # O I PHONE # ; 1--------� -------------------------------------------,-------------------------_-___-----------------------,------------------------------------ A -- ------------------------------------------- TANK --i I ID # TANK SIZE I CHEMICALS STORED CURRENTLY PREVIOUSLY , DATE UST INSTALLED I I I i 39- i I i 39- i------------------------------------------------------------------------------------------------------------------------t-------------------------------------------- 1 I I i I 139- ; ' A 1 I I i I N 39 _ --------------a---------------------------------------------------- ----------+---------------------------------------------{ I I ; ; K I 39- I I39- --------------------------------i 1 - { ------ -------------------------------------------'----------------------------------------------------- '----------------------------------------------------------- -_------'----------------------------------------------` ; P LJ( APPR ED APPROVED WITH CONDITION(S) DISAPPROVED j A /) / �• (S ENT WITH CONDITIONS) i N PLAN REVIEWERS NAME /// DATE I-------`---------------------------------------------------------'--------------------------------------------------------------------------------------------------------------------------------------------- 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF ; I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER 1 AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE 1 CERTIFIES THE FOLLOWING: "I CERTIFY THA IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY i PERSONS SUBJECT TO WORKER'S J�PENTWS OF CALIFORNIA." APPLICANT'S SIGNATURE: TITLE DATE 8/2/2004 --------------------------------------------------------X,------------------------------------------------------------------------------------------------------------------------------------------------------------------iI BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name: Triangle Environmental, Inc Address: 2525 W. Burbank Blvd. Phone #: 818 840 7020