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19255517888 Main Fax GETTLER RYAN INC 0 45:59 P.M. 06-06-2007 416 <br /> ENVIROMMENTAL HEALTH ED'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 /> DANK RETROFIT PIPING REPAIR/RETROFIT [UDC REPAIR/RETROFIT <br /> F EPA Site# CAL000225719 Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> C Facility Name ARCO 2133 Phone# (209)478-5552 <br /> Address 2908 BENJAMIN HOLT DR, STOCKTON, CA 95207 <br /> 1 Cross Stmt PLYMOUTH RD <br /> Y ownerloperator 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 L'IC# 22079.3 Class A.9.CWC37.C6i069 Q_1M <br /> A Insurer STATE COMPENSATION INS FUND work Comp# 238=0003058 <br /> CICC Technician's Certification dumber 5250451-UI Expiration Date 01(17/2009 <br /> T <br /> R ICC Installer's Certification Number 5250451-UT 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 I <br /> P []Approved MApproved with conditions ā¯‘Disapproved <br /> L (See Attachment with Conditions) <br /> A <br /> N Plan Reviewers Nam a qfiIAfiDate <br /> APPLICANT MUST PERFORM ALL WORK IN A ANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 9 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 CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: °I CERTIFY <br /> THAT IN THE PERFORMANCE OF THEWO FOR W ICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Appkantasignatme Tnle AGENT FOR OWNER Date 6/6/2007 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment ooverage 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 Manager PHONE# 925.551.7555 <br /> ADDRESS 6747 SIERRA CJ. SUITZ J DUBLIN 94568 <br /> SIGNATURE <br /> EH230038(revised 8/ / <br /> 1 <br />