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RECEIVEL <br />ENVIRONMENTA <br />HEALTH DEPARTMEN'Fp 17 2015 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HFA 1 TiJ ►ICDA p-4 o r-,, ,- <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 ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Liddy McKenzie (925.551.7555) <br />A <br />C <br />Facility NameCHEVRON SS#201383 <br />Phone# 925.842-1000 <br />� <br />Address 1960 W. 11TH STREET, TRACY, CA <br />TCross <br />Street <br />Y <br />Owner/Operator CHEVRON PRODUCTS COMPANY <br />Phone# <br />C <br />O <br />Contractor Name Gettler-Ryan Inc <br />Phone # (925) 551-7555 <br />N <br />T <br />Contractor Address 6805 SIERRA CT, SUITE G, DUBLIN, CA94568 <br />CA Lic # CIass4.e,�,o.C57,C-61040,HAZ,H�C <br />220793 <br />A <br />insurer State Compensation Ins Fund <br />Work Comp # 9051229-3 <br />T <br />ICC Technician's Name BRIAN GANN <br />Expiration Date <br />R <br />ICC Installer's Name MIKE O'SULLIVAN <br />Expiration Date <br />Tank system work area <br />1/2, <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC etc.) <br />SUPREME UNLEADED <br />12,000 <br />GASOLINE <br />T <br />N <br />DIESEL <br />12,000 <br />DIESEL <br />K <br />REGULAR UNLEADED <br />12,000 <br />GASOLINE <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />N <br />(See Attachment With Conditions) <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE 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: "I 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 <br />TO WORKER'S COMPENSATION LAWS OF C FORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WO FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TOWO KER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature Title AGENT FOR OWNER Date <br />,,,,, <br />BILLING INFOKMAIIUN: <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 by signature and date below. <br />NAME Liddy McKenzie TITLE Project Manaqer PHONE 4925.551.7555 <br />ADDREss6805 SIERRA CT, SWE G D 94568 / <br />SIGNATURE DATE <br />EH230038 (revised 02/20/09 <br />1 <br />