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Eli <br />19255517888 Main Fax GETTLER RYAN INC 3:54 p.m. 01-11-2007 4/11 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />3D4 E WEBER AVE, 3RD 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 />+------------------------------------------------------------------------------------------------------------------------- --+ <br />EPA SITE # I PROJECT CONTACT & TELEPHONE # LIDDY MCKENZIE 925 557.7SSS <br />+-----------------`---------------------------------------`-----------------------------------------------------------------I <br />F 1 FACILITY NAME ARCO PHONE # 925 551.7555 <br />A+------------------ —-----------------------------------------------------------------_------ <br />1 C ADDRESS 3425 TRACY BLVD <br />I--------------------------------------------------------------- -------------------------------------------------------------- <br />L l CROSS STREET 1.5 <br />I+_______________________________________________________________-------------------------------------------------------------- <br />T <br />______________________ _---_T OWNER/OPERATOR 1 PHONE # <br />Y ARCO <br />---+----------------------------------------------------------------------------------+--------------------------------------I <br />C I CONTRACTOR NAME I PHONE # 925 551.7$55 <br />Gettler Ryan Inc. <br />{ 0 +-------------------------- --------------------`------ ----- --------------------- <br />N ; CONTRACTOR ADDRESS 6747 Sierra Court, Suite J Dublin CA LIC If 220793 CLASS A,B,C•10,HA7,C57,CG11IM <br />T+_____________________________________________________________________________________________________________________________1 <br />R t INSURER State Comp Fund <br />WORK.COMP.# 428-2007 ' <br />----------------------------; <br />C OTHER INFORMATION ' <br />--------------------------+--------------------------- ------------1 <br />0 : ; PHONE # 925 551-7555 <br />R+------------------------------------------------------------------------------------+---------------------------------------1 <br />PHONE # <br />" ________________________________________________________________________________- <br />TANKID <br /># TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE USTINSTALLED <br />39- _ -- <br />T 39- <br />A 39- <br />N 39- <br />K 39-- <br />P <br />I, APPROVED APPROVED WITH CONDITION (S) ❑ISAPPROVED «y <br />A E ATTACHMENT WITH CONDITIONS) g - g <br />N PLAN REVIEWERS NAME DATE i j <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 PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE YORKftOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLE Permit. Expeditor DATE <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 />Signature <br />EH230038 <br />(revised 1/31/02) <br />Dublin 94568 Phone # 925 551-7555 <br />1 <br />