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BCE#13438 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ZCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Alexia Inigues / (425) 251-6222 <br /> A <br /> C Facility Name ARCO Fac. No. 2186 Phone# (xxx) xxx-xxxx <br /> I Address 3212 N. California, Stockton, CA 95202 <br /> L <br /> TCross Street <br /> Y Owner/Operator BP West Coast Products, LLC Phone# (510) 432-8397 <br /> C Contractor Name Gettler Ryan Inc. <br /> O Phone# 925-551-7555 <br /> N Contractor Address 6747 Sierra Court Suite J. <br /> T CA LIC# 220793 Class C57,B,D4o,A,c10 <br /> RInsurer STATE COMPENSATION INSURANCE FUND <br /> A Work Comp# 238-0003058 <br /> T ICC Technician's Certification Number (SEE ATTACHED) Expiration Date (SEE ATTACHED) <br /> R ICC Installer's Certification Number (SEE ATTACHED) Expiration Date (SEE ATTACHED) <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P Approved ❑Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date fib <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title environmental Compliance Specialist Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. Jj r D A NA eJ-kK _ C� <br /> NAME I, "`� TITLE HONE# <br /> ADDRESS l �D<" l� 03 � �`TC'\a�G� I ���2 <br /> ` <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />