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19255517888 Main Fax GETTLER RYAN INC 12 '3:36 p.m. 09-20-2007 5112 <br />w <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, 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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />UTANK RETROFIT PIPING REPAIRIRETROFIT EUDC REPAIR/RETROFIT <br />F <br />EPA Site # CAL000225724 <br />Project Contact & Telephone # Liddy McKenzie (925.551.7555) <br />Facility Name ARCO -2186 <br />Phone # (209) 941-2694 <br />IAddress <br />L <br />3212 N CALIFORNIA, STOCKTON, CA 95204 <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator BP West Coast Products LLC <br />Phone # <br />C <br />Contractor Name Gettler-Ryan Inc <br />Phone # (925) 551-7555 <br />O <br />N <br />T <br />Contractor Address 6747 SIERRA CT, SUITE J, DUBLIN, CA94568 <br />CA Lic # 220793 Class A,8,C10C57,Cb1IW0,MAZ.NIC <br />A <br />Insurer STATE COMPENSATION INS FUND <br />work comp# 238-0003058 <br />C <br />T <br />ICC Technician's Certification Number 5254810 -UT <br />Expiration Date 06/28/2009 <br />R <br />ICC Installer's Certification Number 5254810 -UI <br />Expiration Date 06/28/2009 <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />DApproved Approved with conditions ā¯‘Disapproved <br />L <br />A <br />(See A achment With Conditions) <br />cyz <br />N <br />Plan Reviewers Name Date <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 AGENT'S 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 CA ORNI TRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF E WO FO HIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Aoolicants Sia nature Title AGENT FOR OWNER Date 9/20/2007 <br />J 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 />NAME <br />Liddy McKenzie TITLE Project Manaqer PHONE # 925.551.7555 <br />ADDRESS 6747 SIERRA QT, VJITE ,L,DU.BLIN <br />SIGNA <br />EH230038 (revised 8/8/06) <br />1 <br />