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a 9255517888 Main Fax GETTLER RYAN INC 5:58 p.m. 09-07-2007 5/6 <br /> ENVIRONMENTAL HEALTH wu"'EPARTMENT <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 /> TANK RETROFIT +PIPING REPAIR/RETROFIT UUDC REPAIRIRETROFIT <br /> F EPA Site# CAL000225719 Praject Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> C Facility Name ARCO 2133 Phone# (209) 478-5552 <br /> IAddress 2908 BENJAMIN HOLT DR, STOCKTON, CA 95207 <br /> L <br /> I Cross Street PLYMOUTH RD <br /> T <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> o Contractor Name Gettler-Ryan Inc Phone# (925) 551-7555 <br /> N Contractor Address 6747 SIERRA CT,SUITE J,DUBLIN,CA94568 CA Lie# 22Q793 CIaSS as.c+ocsv,c$t�o-,o,rwz+ic <br /> T <br /> A insurer STATE COMPENSATION INS FUND Work Comp# 238-0003058 <br /> T ICC Technician's Certification Number 5250451-UT Expiration Date 01/17/2009 <br /> Q <br /> R ICC Installer's Certification Number 5250451=U1 Expiration Date 05/25/2009 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ClApproved RApproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date�Tjl�d1 <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 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 WO FO ICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA." / <br /> Applicants Signature Title AGENT FOR OWNER Date 9/7/2007 <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 /> ADDRESS 6747 SIERRA CTS ITE DUBLIN 94568 <br /> SIGNATURE ' <br /> EH230038(revised 8/8/06) <br /> 1 <br />