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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> 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# Project Contact&Telephone#MERLIN BOWEN 925.551.7555 <br /> A <br /> C Facility Name ARCO SS#6080 Phone#209.983.9144 <br /> I <br /> L Address 85 E. LOUISE STREET <br /> T Cross Street HARLAN ROAD <br /> Y Owner/Operator BP ARCO WEST COAST PRODUCTS LLC Phone#530.470.6133 <br /> o Contractor Name Gettler Ryan Inc. Phone#925.551.7555 <br /> N <br /> T Contractor Address 6805 Sierra Court, Suite G, SUITE G CA Lic#220793 ClassA/B/C61-D40/CI <br /> A Insurer State Compensation Ins Fund Work Comp#9051229-3 <br /> T ICC Technician's Name TIM PERRY Expiration Date 3/22/2020 <br /> R ICC Installer's Name TIM PERRY Expiration Date 3/22/2020 <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 DROP TUBE, BALL FLOAT CAGE 20,000 GASOLINE UNKNOWN <br /> A DROP TUBE, BALL FLOAT CAGE 10,000/12,000 GASOLINE UNKNOWN <br /> N <br /> K <br /> P ❑ ApprovedApproved with conditions ❑ Disapproved <br /> L (See A chment With Conditions) <br /> A �y <br /> N Plan Reviewers Name ., Date- U Cy <br /> APPLICANT MUST PERFORM ALL WO 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 CALIFORNI CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FO ICH 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 Date 9/05/2018 <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 Project Manager PHONE#925.551.7555 <br /> ADDRESS <br /> 6805 SIERRA CT, SUJTEG, DUBLIN, 94568 <br /> SIGNATURE DATE <br /> EH230038(revised 07-17-2014) <br /> 2 <br />