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19255517888 Main Fax GETTLER RYAN INC 1" "1:14 a.m. 03-09-2007 4/11 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD 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/RETROr1T_UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> ------------------------------------------------------------------------------------------- ----------------------------+ <br /> EPA SITE # I PROJECT CONTACT & TELEPHONE # LIDDY MCKENZIE 925 551-7555 <br /> _________________________________________________________________________________________________________________-__--_--____- <br /> F FACILITY NAME UNION766100 PHONE # 925 551-7555 <br /> A ---- ------------ <br /> C ; ADDRESS 25775 S PATTERSON PASS <br /> I +---------------- ------------------- --- ------------------------------ <br /> L ; CROSS STREET <br /> I +____________________ __-________-__ <br /> T ; OWNER/OPERATOR PHONE # <br /> Y ; UNION 76 <br /> ;---*---------- ------------------ <br /> - -------------------------- <br /> C CONTRACTOR NAME Gettler Ryan Inc. I PHONE #925 551-7555 <br /> 0 ---------------------------- <br /> N CONTRACTOR ADDRESS 6747 Sierra Court,Suite J Dublin CA LIC # 220793 I CLASS a,b,C-10,ha2.C57,C61,d40 <br /> T +------------------------------------------ ------ ----------------- ----------- <br /> R <br /> ------------------------------------ <br /> R 1 INSURER State Comp Fund ; WORK-COMP.# 428.2007 <br /> ________________________ <br /> C OTHER INFORMATION <br /> 0 ; PHONE #925 551-7555 <br /> R <br /> PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE DST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> I N ; 39- <br /> K ; 39- <br /> 39- <br /> 39- <br /> L APPROVEDI �APPROVEDIWITH CONDITION1(S)' 1DISAPPROVEDI <br /> y A 1 1 1'1, ,11 I,I'-�(�^ 1 IS ATTACHMENT WITH CONDITI0NS1 1 1,.- 1 /1j1 1'"•�' <br /> N ; PLAN REVIEWERS NAME VV• JVD DATE ��l�V, <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 PERFOR CE OF 3HE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNI ^ <br /> 1 <br /> APPLICANT'S SIGNATURE: TITLE Agent for Owner DATE 3/9/2007 <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 /> 6747 Sierra Court,Suite J <br /> Name LIDDY MCKEN Address Dublin 94568 Phone# 925 551-7555 <br /> Signature <br /> E H230038 <br /> (revised 1/31/02) <br /> 1 <br />