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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <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 0 COLD STARTIEVR UPGRADE <br /> F EPA Site# FA0003199 Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> A <br /> Facility NameWOODBRIDGE AMPM Phone# 209.339.8238 <br /> 1Address 18806 LOWER SACRAMENTO ROAD, WOODBRIDGE, CA 95258 <br /> T Cross street INDIANA STREET <br /> Y OwnerlOperator JASS ENTERPRISES Phone# (209)339.8238 <br /> o Contractor NameGETTLER-RYAN, INC Phone# (925)551.7555 <br /> N <br /> T Contractor Address 6805 SIERRA COURT,SUITE G,DUBLIN,CA 94568 CA Lic# 220793 ClaSSA„e,C10,C-e11Dd0,HAZ <br /> A Insurer Zurice Amer Ins Co Work Comp# WC09046340 <br /> CICC Technicians Name <br /> T ' (�xfj� T,gTE Expiration date O <br /> 0 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (1.e 87 Aping sump,91 leak detector,UOC 112,etc.) Installed <br /> T PREMIUM UNLEADED 12,000 91 GASOLINE <br /> N REGULAR UNLEADED 12,000 87 GASOLINE <br /> K DIESEL 12,000 DIESEL <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 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING '1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS RMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFOR CONTRALTO IRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. 'l CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK F ICH THIS TIS SSUED,I SHALL EMPLOY PERSONS SURJEC7 TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' <br /> Applicant's Signature T1Ue AGENT FOR OWNER Date 11/02/2020 <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 by signature and date below. <br /> NAMELiddv McKenzie TITLE Project Manaqer PHONE#925.551.7555 <br /> ADDRESs68O5 SIERRA CT, SUITE G2 DUBLIN, 94568 <br /> SIGNATURE DATE 11/02/2020 <br /> EH230D38(revised 07120109) <br /> 1 <br />