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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 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 # ; PROJECT CONTACT & TELEPHONE # Eric Janzen (707) 789-3255 <br />+---------------------------------------------------------------------------------------------------------------------------- <br />F I FACILITY NAME ConocoPhillips 2611194 ; PHONE # <br />A+-------------------------------------------------------------------------------------- ------------------------------------- <br />C ; ADDRESS 2375 Tracy Blvd. Tracy CA <br />I+-----------------------------------------------------------------------------------------------------------------------------; <br />L ; CROSS STREET Grant Line Road <br />I+----------------------------------------------------------------------------------- ------------------ ----' <br />Y OWNER/OPERATOR ConocoPhillips PHONE # (916) 558-7649 Ext. <br />;--+------------------------------------------------------------------------------------+- ------------------------------------- <br />C ; CONTRACTOR NAME Gettler-R an Inc. ; PHONE # (707� 789-3255 Ext. 18 <br />0+---------------------------------------------------y--------------------------------------------- -------------------------' <br />N ; CONTRACTOR ADDRESS 1364 N. McDowell Blvd Suite B2 ; CA LIC # 220793 ; CLASS A, B, Haz <br />T ----------------------------------------------- ------------------------------------------------------- <br />--------------------------------------------------------------------------------------------------- -------------------- <br />R INSURER State Compensation Insurance Fund ; WORK.COMP.# 428-2004 <br />A-------------------------- --------------------- ---------------------------------+------------------------- -------------; <br />C ; OTHER INFORMATION <br />+----------------------------------------; <br />O PHONE # <br />R+------------------------------------------------------------------------------------ PHONE # <br />---------------------------------------------------------------------------------------------- <br />TANK ID #III'IIIIIIi TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br />39- 2611194 WO 550 waste oil <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />i <br />P <br />L APPROVED IAPPROVED WITH CONDITION(S) DISAPPROVED <br />A �/� (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME �IlJ� DATEL <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 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLE Agent for ConocoPhillips DATE <br />, <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 />Name Gettler-Ryan Inc <br />Sign <br />EH230038 <br />(revised 1/31/02) <br />ress 1364 N. McDowell Blvd. Suite B2 Phone # (707) 789-3255 <br />Petaluma <br />1 <br />CA 94954 <br />