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9255517888 Line 13:11:33 08-17-2012 4/15 <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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT iZ COLD STARTIEVR 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 <br /> L Address 3212 N CALIFORNIA, STOCKTON, CA 95.204 <br /> 1 Cross Street Alpine Avenue <br /> T <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> o Contractor NameGettler-Ryan Inc Phone (925) 551-7555 <br /> T Contractor Address 6747 SIERRA CT,SUITE J,DUBLIN,CA94568 CA Lic# 220793 C l as ssB.G,C.C57,p6�DQ.KAZHc <br /> A Insurer STATE COMPENSATION INS FUND work Comp# DTJUB78P1510 <br /> 7 ICC Technician's Name Christopher San Nicolas Expiration Date 01/24/2013 <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e,87 p ping sump,91 leak detector,UDC 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions Disapproved <br /> L ( ee Att ment With Conditions) <br /> N Plan Reviewers Name / Date j— 2 r 2- -- <br /> APPLICANT MUST PERFORM ALLRK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMEN AL 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 <br /> TO WORKER'S COMPENSATION LAWS 0,F CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE ORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title AGENT FOR OWNER Date08/17/2012 <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 1T B 568 <br /> SIGNATURE DATE <br /> EH230038(revised 0 09) <br /> 1 <br />