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19255517888 Main Fax GETTLER RYAN INC "^"14:22 a.m. 05-23-2007 5111 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,e'FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> --------------------------------------------------------------------------------------------------------------EPA SITE # --------------+ <br /> +-_--_ <br /> . � ; PROJECT CONTACT 6 TELEPHONE # LIODY MC KENZIE 925 _ SS1_T55S <br /> -- --- -----1 <br /> F ; FACILITY NAME ARCO-6080 _PHONE # 925 551.7555 <br /> A _______________________ <br /> C 1 ADDRESS BSELOUISEAVE <br /> I ------------------------------------------------------------- <br /> L 1 CROSS STREET ' <br /> I +------------------------------------------------------------------------------------------------------------------ <br /> T OWNER/OPERATOR PHONE # <br /> Y ARCO <br /> '---+----------------------------------------------------------------------------------+----------------------------------------1 <br /> C 1 CONTRACTOR NAME Oettler Ryan Inc, : PHONE #925 551-7555 <br /> O +---------------------------------------------------------------------------------------------------------------- <br /> N 1 CONTRACTOR ADDRESS 8747 Sierra Court,Suite J Dublin CA LIC # 220793 1 CLASS a,D,C40,haz,C57.C61,d40 <br /> T +-----------------------------------------------------------------------------------------------------------------------------1 <br /> 1 R 1 INSURER State Comp Fund 1 WORK.COMP.# 428.2007 <br /> A '------------------------------------------------------------------------------------------------------------------ <br /> C OTHER INFORMATION ' <br /> T +------------------------------=-----------------------------------------------------+----------------------------------------1 <br /> 0 : PHONE # 925 551-7555 <br /> 1 R +------------------------------------------------------------------------------------+----------------------------------------1 <br /> PHONE # <br /> --------------------------------------------------------------------------------------------- <br /> ; TANK ID # 1 TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED 1 <br /> 39- <br /> 3 39- <br /> A 39- <br /> N 1 39- <br /> K 39- <br /> 39- <br /> L APPROVED ✓ APPROVE WITH CONDITION(S) DISAPPROVED <br /> A (SE TTAC WITH CONDITIONS) <br /> N 1 PLAN REVIEWERS NAME L I L���L�t,i��L/`�/ -�'�tL�,i l� DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PER IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF C IN ." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF WOR FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> 1 APPLICANT'S SIGNATURE: TITTLE Agent for Owner DATE 5!2212007 <br /> +----------------------------------------- ------------------------------+ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> 6747 Sierra Court,Suite J <br /> Name LIDDY MCKENZIE Ad ess Dublin 94568 Phone# 925 551-7555 <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />