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925551788 Line 1 P-1-23 p.m. 02-11-2009 5/12 <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 /> ❑TANK RETROFIT CJPIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# CAL000225724 Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> A <br /> C Facility Name ARCO-2186 Phone# (209) 941-2694 <br /> 1Address 3212 N CALIFORNIA, STOCKTON, CA 95204 <br /> L <br /> TCross Street <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> cContractor Name Gettler-Ryan Inc Phone# (925) 551-7555 <br /> 0 <br /> N Contractor Address 6747 SIERRA CT,SUITE J,DUBLIN,CA94568 CA Lic# 220793 Class ne,cm,cn,cc+m+o,ruz.wc <br /> T <br /> A Insurer STATE COMPENSATION INS FUND Work Comp# 238-0003058 <br /> T ICC Technician's Certification Number 5300833-UT Expiration Date 06/28/2009 <br /> o <br /> R ICC Installer's Certification Number 5300833-UI Expiration Date 06/28/2009 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P proved pproved with conditions ❑Disapproved <br /> L ee Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name _ Date <br /> APPLICANT MUST PERFORM ALL W KIN 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 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 AGENT FOR OWNER oat, 02/11/2009 _ <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 /> NAME <br /> Liddy McKenzie TITLE Project Manaqer _PHONE# 925.551.7555 <br /> ADDRESS 6747 SIERRA CT, SUITE J, DUBLIN, 94568 <br /> SIGNATURE <br /> EH230038(revised 818/06) <br /> 1 <br />