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9255517888 Line 1030 p.m. 10-31-2008 3/3 <br /> 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT PIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# CAL000225805 Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> A Facility Name ARCO 5450 Phone# (209) 983-9140 <br /> I <br /> L Address 1617 W FREMONT ST, STOCKTON, CA 95203 <br /> TCross Street <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> C <br /> 0 Contractor Name Gettler-Ryan Inc Phone# (925) 551-7555 <br /> N Contractor Address 6747 SIERRA CT,SUITE J,DUBLIN,CA94568 CA Lic# 220793 Class aa.c,o.csr,aavoao,wsrxc <br /> T <br /> A Insurer STATE COMPENSATION INS FUND Work Comp# 238-0003058 <br /> C <br /> T ICC Technician's Certification Number 5252010-UT Expiration Date 06/07/2009 <br /> R ICC Installer's Certification Number 5252010-UI Expiration Date 12/28/2008 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approvedpproved with conditions ❑Disapproved <br /> L (Se Attachment With Conditions) (� <br /> A � U <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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR W H THIS PE MIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OFC _OH <br /> TRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE FOR IS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title AGENT FOR OWNER_Date 10-31-2008 <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 /> NAME Liddy McKenzie TITLE Project Manager _PHONE# 925.551.7555 <br /> ADDRESS 6747 SIERRA CTJ SA J BLIN, 94568 <br /> SIGNATURE <br /> EH230038(revised 818/06) <br /> 1 <br />