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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 />1Z TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # MERLIN BOWEN (925.551.7555) <br />A <br />C <br />Facility NameARCO 5450 <br />Phone # <br />I <br />L <br />Address 1617 W FREMONT STREET <br />1 <br />Cross Street INTERSTATE HWY. 1-5 <br />T <br />Y <br />Owner/Operator BP West Coast Products LLC <br />Phone # (360) 371-1500 <br />c <br />Contractor NameGettler-Ryan Inc <br />Phone # (925) 551-7555 <br />T <br />Contractor Address 6805 SIERRA CT, SUITE G, DUBLIN, CA94fi <br />CA Lic# 220793 ClassA,B,C10,C57,JJ <br />RA <br />Insurer Travelers Property Casulty Co <br />Work Comp # DTJUB78P41510 <br />C <br />T <br />ICC Technician's Name RYAN MATTHEWS <br />Expiration Date <br />o <br />R <br />ICC Installer's Name CHRIS SAN NICOLAS <br />Expiration Date 12/06/2013 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See-Altpchment With Conditions) <br />A <br />NPlan <br />q <br />Reviewers Name �_ i -/ ate *12-11,3 <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 CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature,,e!!!?-&/f/-t ��"J Title AGENT FOR OWNER Date11/05/2013 <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 />MERLIN BOWEN TITLE Project Manager <br />ADDRESS6805 SIERRA CT, SUITE G, DUBLIN, 94568 <br />PHONE #925.551.7555 <br />SIGNATURE /&4//"� DATE 11/05/2013 <br />EH230038 (revised 02/20/09) <br />1 <br />