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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL H ALTH DEPARTMENT <br /> 304 E WEBER AYE,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 REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +---------- ---- --- --------- --------------------------------+ <br /> EPA.SITE # ; PROJECT CONTACT & TELEPHONE # Scott Polston 925 551-7555 <br /> F ; FACILITY NAME Bp Oil PHONE # 925 551-7555 <br /> A +------------------------------------------------------------------- -- - --' <br /> C ; ADDRESS 3250 West Hammer Lane <br /> I +------------------------ --------- ------------------------------------- <br /> L ; CROSS STREET Kelley Drive <br /> I +-------------------------------------------------------------------------------- <br /> T OWNER/OPERATOR PHONE # <br /> Y BP Oil (209)957-2900 <br /> ---------- -----------+-------------- <br /> C CONTRACTOR NAME Gettler Ryan Inc. PHONE #925 551-7555 <br /> N ; CONTRACTOR ADDRESS 6747 Sierra Court,Suite J Dublin CA LIC # 220793CLASS a,b,c-10,haZ,c57,c61,d40 <br /> T +---------------------------------------- --------------------------------------------- <br /> R INSURER State Fund WORK.COMP.# 426-2004 <br /> A ,_ ___ _______________________________________________________+___________ <br /> C OTHER INFORMATION <br /> O PHONE # 925 551-7555 <br /> PHONE # <br /> ___________________ ______ <br /> TANKID # TANK SIZE C __________________________________________________________ <br /> ' <br /> ' �EMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39 <br /> P <br /> L APPROV PPROVED WITH CONDITION DISAPPROVED <br /> A ,�(SE ATTACHMENT WITH CONDITIO ) <br /> N PLAN REVIEWERS NAME DATE <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 TH ERFORMANCE OF ORK FO2 WH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF C IFO A." <br /> APPLICANT'S SIGNATURE 4. TITLE Permit Expeditor DATE l! <br /> --------------------------------------------------------------------------------------------------------------------------------q <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 /> Name Scott F ) t0 Add S ublin 94566 Phone # 925 551-7555 <br /> Signature <br /> EH230038 �� Yall <br /> (revised 1/31/02) <br /> 1 <br />