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9255517899 Line 1 ;22 p.m. 10-20-2010 3/8 <br /> LNVIRONANTAL <br /> SANJOAQUINCOUNTY <br /> 600 East Main Street,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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT 1Z PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> � Facility NameCIRCLE K (2705446) Phone# 209-943-2082 <br /> 1 Address 1403 COUNTRY BLVD <br /> L <br /> TCross Street <br /> Y Owner/Operator MICHELLE CASTLE Phone# <br /> c ContractorNameGettler-Ryan Inc Phone# 925) 551-7555 <br /> T Contractor Address 6747 SIERRA CT, SUITE 3, DUBLIN,CA94568 CA Lic# 220793 ClasS06 C97,c-61/o40, <br /> A Insurer TRAVELER'S PROPERTY CASUALTY CO. Work Comp# DTIUB78P41510 <br /> C <br /> T ICC Technician's Name CHRIS BISHOP Expiration Date 05/14/2012 <br /> R ICC Installer's Name CHRIS BISHOP Expiration Date 06/18/2012 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> [tie.87 piping sump,91 leak detector,UDC V2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved 'Approved With conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL W K IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEA4TH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR HICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS O CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE RK FOR HIS PERMIT IS ISS HALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPS ATION LAWS <br /> OF CALIFORNIA." 4E <br /> ol <br /> 7 /ApplicarttsSi mature Title1 Date t �' <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 b signature and date below. <br /> NAMEilo c Z I ..TITLE PHONE# <br /> ADDRESS AA <br /> SIGNATURE DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />