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19255517888 Main Fax GETTLER RYAN INC 11:55:14 a.m. 12-20-2006 4/11 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WESER 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/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +------------------------------ ------------------------------------------------------------------------------------------------+ <br /> EPA SITE # ; PROJECT CONTACT & TELEPHONE # LIDDYMCKENZIE ps 551-7SSi <br /> , <br /> F <br /> A +-FACILITY NAME-------------ARCO------------------ ; PHONE # 925 551.7555 <br /> ; C ; ADDRESS 3212 N CALIFORNIA <br /> L 1 CROSS STREET 1 - <br /> 1.5 <br /> T OWNER/OPERATOR ; PHONE If <br /> Y ARCO <br /> , <br /> 1_ _+________________________________________ ' <br /> C CONTRACTOR NAME Gettler Ryan Inc. I PHONE #925 --- -551-7555__ ---- - ___ <br /> , <br /> ' 0 +------------------------------- ------------------------------------------------------------------------ <br /> N CONTRACTOR ADDRESS 6747 Sierra Court,Suite J Dublin <br /> ; CA LIC # 220793 CLASS a,------------- 1,d40 <br /> T +----------------- ; <br /> R ; INSURER State Comp Fund ; WORK.COMP.# 423.M7 ; <br /> A ;----------------------------------- -------------------------------------------+--------------------------------------' <br /> I C I OTHER INFORMATION <br /> ---------'- <br /> O ; <br /> R +--- ; PHONE #925 551-7555 <br /> ' PHONE # <br /> --------------------------------------------------- --------------- <br /> — <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 1 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> LI It/ <br /> PPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> /G <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 /> BECK SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE F THE RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE,: TITLE Permit Expeditor DATE <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 MCKENZIE Address Dublin 94568 Phone # 925 551-7555 <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />