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9255517888, Line 11 3 p.m. 03-04-2010 4/13 <br /> tNVIRONN&TAL 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 /> 1Z TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ 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 /> 1 Cross Street HARLAN <br /> T <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> o Contractor Name Gettl er-Ryan Inc Phone# (925) 551-7555 <br /> T Contractor Address 6747 SIERRA CT,SUITE J, DUBLIN,CA94568 CA Lic# 220793 Cl2SSoe.c,o.csr.cevwo,Ha.wc <br /> A insurer STATE COMPENSATION INS FUND Work Comp# 238-0003058 <br /> T ICC Technician's Name 8018952-UT Expiration Date 04/02/10 <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1P2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved roved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Pian Reviewers Name Date—::d, <br /> APPLICANT MUST PERFORM ALL WORK 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 F CALIFO IA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF TH ORK 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 Date03/02/2010 <br /> BILLING INFORMATION: <br /> Indicate the responsible party Lii-11'e'd 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 Manager PHONE#925.551.7555 <br /> ADDREss6747 SIERRA CTe)SUITFr J DUBLIN 94568 �7 <br /> SIGNATURE DATE v <br /> EH230038(revised 02/201 <br /> 1 <br />