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0 • <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT X PIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +-------------------------------------------------------- ---- --�--+ <br /> EPA SITE # - _ _ I PROJECT CONTACT & TELEPHONE # Kathy Smith (31 O) 323-6730_eXt LV7� <br /> +--- --2 <br /> F ; FACILITY NAME ; PHONE # 209 <br /> A +______________________Arco-5450 <br /> __ (_ _ ) 462-1617 <br /> ADDRESS________________________________161.7 W. Fremont Ca. 95203 <br /> L ; CROSS STREET Interstate-5 <br /> I +------------------------------------- <br /> i-T I OWNER/OPERATOR PHONE # <br /> Y + BP West Coast Products LLC 760 746 - 0030 <br /> ------)------------------ <br /> C CONTRACTOR NAME Charles E. Thomas-Co. PHONE # �_3.1_.0_)3_23_-_67.30__ex_t_.__2.59_ <br /> 13701 SAlma ardenaCa90249; CA LIC # CLASS <br /> N S. Ave.. , .CONTRACTOR ADDRESS 302015 ----- C1- -------- ---- -- <br /> R ; INSURER State Fund ; WORK.COMP.# 176608904 <br /> A '---------------------------------------------------------------------------+- <br /> C OTHER INFORMATION <br /> , <br /> 0 , PHONE # <br /> ' R + <br /> PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> I1TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 12,000 gallons 91 octane tank Unknown <br /> T 39- 12.000 gallons 87 octane gasoline master tank Unknown <br /> A 39- 12.000 gallons 87 octane gasoline slave tank Un knov�n <br /> N 1 39- <br /> K 39- <br /> 39- <br /> 39- <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A �/� (SEE ATTACHMENT WITH CONDITIONS) <br /> � <br /> N PLAN REVIEWERS NAME Wrl I&M DATE IZ'ZI'OS <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO , <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: �iFi TITLE Permit Agent DATE <br /> +------- - ---------- ------ ----- <br /> -+ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Address Phone # <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />