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9255517888 Line 1 11:39:07 05-14-2013 4!11 <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 /> 10 TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# CAL000225724 <br /> A Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> C Facility NameARCO-2186 Phone# (209) 941-2694 <br /> I <br /> L Address 3212 N CALIFORNIA, STOCKTON, CA 95204 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> o Contractor NameGettler-Ryan Inc Phone# (925) 551-7555 <br /> N <br /> T r,cContractor Address 6747 SIERRA CT,SUITE J,DUBLIN,CA94568 CA Lic# 220793 C lasso e,c,o,ces,mao.w�z,r,c <br /> A insurer STATE COMPENSATION INS FUND work Comp# 9051229-13 <br /> C ICC Technician's Name p 09/13/2013 <br /> T Chris Reeves Expiration Date <br /> o <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 teak detector,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved aApproved with conditions LJ Disapproved <br /> L %(See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name / Date_ <br /> APPLICANT MUST PERFORM ALL14ORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT,OW ER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THI ER SUED,I SHALL NOT EMPLOY ANY PERSON 1N SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS F CALIFO A." ACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE PERFORMANCE OF TH JORK FO IS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature_ _ Title AGENT FOR OWNER Date05/14/2013 <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 Liddy McKenzie TITLE PrOied Manager PHONE 4925.551.7555 <br /> ADDRESs6747 SIERRA CT SUITE J. DUBLIN. 94568 <br /> SIGNATURE _DATE <br /> EH230038(revised 02/ / <br /> 1 <br />