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9255517888 Line 10 Iq:20a.m. 10-27-2008 5/11 <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 /> r <br /> L. TANK RETROFIT PIPING REPAIRMETROFIT F_;UDC REPAIR/RETROFIT <br /> F EPA Slte# CAL000225805 Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> A <br /> C Facility Name ARCO 6080 Phone# (209) 983-9140 <br /> 1Address 85 E LOUISE AVE, LATHROP, CA 95330 <br /> L <br /> TCross Street <br /> Y Owner/Operator BP West coast Products LLC Phone# <br /> C Contractor Name Gettler-Ryan Inc Phone# (925) 551-7555 <br /> 7 Contractor Address 6747 SIERRA CT,SUITE J,DUBLIN,CA94568 CA Li # 220793 Class AACMCW.0 1040A.74We <br /> A Insurer STATE COMPENSATION INS FUND work comp# 238-0003058 <br /> T ICC Technician's Certification Number 532633-UT Expiration Date 01/07/2009 <br /> R ICC Installer's Certification Number 532633-UT Expiration Date 01/07/2009 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P QApproved Approved with conditions L—Disapproved <br /> L ee Attachmeo With Conditions) <br /> A <br /> N 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR W ICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OFC IFORNI CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE W K FOR I H THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' <br /> ApplicantsSlgnatureTina AGENT FOR OWNER Data 10-27-2008 <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 Proiect Manaqer PHONE It 925.551.7555 <br /> ADDRESS 6747 SIERRA CTZ SUM J DUBLIN 94568 <br /> SIGNATURE <br /> EH230038(revised 8!8/06) <br /> 1 <br />