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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3 R 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 PIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +---------------------------------------------------------------------------------------------------------------------------------+ <br /> +_ EPA SITE <br /> _#_ __________________________________PROJECT CONTACT-& TELEPHONE_#_Kathy)-Smith (310 323-6730 0 -ext-267: <br /> F FACILITY NAME PHONE # 209 830-8142 <br /> A +----------------------Arco_6347--------------------------------------------------------------(-----�83 -- 142------; <br /> C , ADDRESS 2430 Joe Pumbo_Parkwa�____Tram Ca_ 95376 _ _______! <br /> I +-------- - <br /> L ; CROSS STREET Grant Line <br /> I +---------------------------------------' -- -- ------------------ <br /> T OWNER/OPERATOR PHONE # <br /> Y + BP West Coast Products LLC (7600 746 - 0030 <br /> C I CONTRACTOR NAME Charles E. Thomas Co. ;_PHONE # 310 323-6730 ext. 259; <br /> ----------------- ------ -- ----- - - --------------------- -- -------------------------------------------; <br /> N + CONTRACTOR ADDRESS 13701 S. Alma Ave. Gardena, Ca. 90249; CA LIC # 302015 ; CLASS C10,C61040, Haz,A <br /> T +-------------------------------------------------------------------------------------- --------------------------------------, <br /> R ; INSURER State Fund ; WORK_COMP.# 1 7660 8904 <br /> A '----------------------------------------^ <br /> C OTHER INFORMATION <br /> T +----------------------------^------------------------------------------------------+--------------------------------------- <br /> O PHONE # <br /> PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK ID # I1"IIj1j TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 20,000 gallons 87 octane tank Unknown <br /> T 39- 10.000 gallons 87 octane slave tank Unknown <br /> A 39- 12,000 aallons 91 octane tank Unknown <br /> N 39- <br /> K ; 39- <br /> 39- <br /> 39- <br /> P <br /> L ; APPROVED APPROVED WITH CONDITIONS) DISAPPROVED -f <br /> N PLAN REVIEWERS NAME_.�GI (SEE ATTACHMENT WITH CONDITIONS) DATE ( O, <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 /> r Permit Agent /Z /1J s <br /> APPLICANT'S SIGNATURE: � !� TITLE DATE / ; <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 />