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9255517888 Line 1 11-n9-177 a.m. 07-01-2009 4/13 <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 ❑ COLD START/EVR UPGRADE <br /> F EPA Site# CAL000225724 Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> A <br /> C Facility NameARCO-2186 Phone# (209) 941-2694 <br /> I Address 3212 N CALIFORNIA, STOCKTON, CA 95204 <br /> L <br /> TCross Street <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> C Contractor Name Gettler-Ryan Inc Phone# (925) 551-7555 <br /> 0 <br /> N Contractor Address <br /> T 6747 SIERRA CT,SUITE J,DUBLIN,CA94568 CA Lic# 220793 ClaSsoe.c,o.cszca+rwo,Naz,Nic <br /> A Insurer STATE COMPENSATION INS FUND Work Comp# 238-0003058 <br /> T ICC Technician's Name 8018952-UT Expiration Date 04/02/2010 <br /> R ICC Installer's Name 8018952-UI Expiration Date 04/02/2010 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector.UDC 1/2,etc-) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved --it:Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date v <br /> APPLICANT MUST PERFORM ALL ARK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PE T IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OFFCIFORNIA." NTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WOOR yY THIS PER IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title AGENT FOR OWNER Date07/01/2009 <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. <br /> NAMELiddy McKenzie TITLE Project Manaqer PHONE#925.551.7555 <br /> ADDRESs6747 SIERRA CT, SUITE J, DUBLIN, 94568 <br /> SIGNATURE DATE <br /> EH230038(revised 02120/09) <br /> 1 <br />