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9255517888 Line 10 01p.m. 03-02-2010 4/16 <br /> LNVIRONMftTAL HEALTH UEARTMENT <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 REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ,❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> A <br /> C Facility NameARCO 6080 Phone# <br /> Address 85 E LOUISE AVE, LATHROP, CA 95330 <br /> L <br /> 1 Cross Street <br /> T HARLAN <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> C Contractor NameGettler-Ryan Inc Phone# (925) 551-7555 <br /> T Contractor Address 6747 SIERRA CT,SUITE J,DUBLIN,CA94568 CA Lic# 220793 ClasSae,c10,c57,cs,m40,uz.Hic <br /> A Insurer STATE COMPENSATION INS FUND work Comp# 238-0003058 <br /> 7 ICC Technician's Name 5238552-UT Expiration Date 06/30/2010 <br /> R ICC Installers Name 5250453-Ul Expiration Date 12/30/2010 <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 <br /> A <br /> N <br /> K <br /> P ❑ Approved 19 Approved With conditions Disapproved <br /> L (See'Attachment With Conditions) <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 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 OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WOR R WHICH PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title AGENT FOR OWNER Date03/02/2010 <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 Manaqer PHONE#925.551.7555 <br /> ADDRESs6747 SIERRA CT SUITE J DUBLIN 94568 <br /> SIGNATURE DATE <br /> EH230038(revised 02/ /0 <br /> 1 <br />