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9255517888 Line 09:17:56 06-22-2015 5/12 <br /> 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 /> 17 TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> A <br /> C Facility NameARCO 5450 Phone# <br /> L Address 1617 W FREMONT, STOCKTON <br /> I Cross Street <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> C Contractor NameGettier-Ryan Inc Phone# (925) 551-7555 <br /> N Contractor Address 6805 SIERRA CT,SUITE G,DUBLIN,CA94568 CA Lic# 220793 Classtiec,o.csr.ce,csvw�xoc <br /> R Insurer State Compensation Ins Fund Work Comp# 9051229-3 <br /> T ICG Technician's Name CHRIS SAN NICOLAS Expiration Date 03/17/2017 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Da �l VELJ <br /> .4 ktp(i.e.87 piping sump,91 leak detector,UDC U2,etc.) <br /> r <br /> A <br /> K 015 <br /> ENVIRnN ENTAL. <br /> `�eA�*�►�cDA7rr4APNT <br /> P ❑ Approved Approved with conditions ElDisapproved <br /> L e Attachment With Conditions) <br /> A . <br /> N r_ _ — <br /> Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACC ANCE 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: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR W ICH THIS PERMIT)S ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF ALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE RK FOR H PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title AGENT FOR OWNER Date06/15/2015 <br /> BILLING INFORMATION: <br /> Indicate the re sible 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 /> NAMELiddy McKenzie TITLE Project Manaqer PHONE#925"551.7555 <br /> ADDREss6805 SIERRA CT SUITE G LIN 94568 f <br /> SIGNATURE DATE / <br /> EH23DO38(revised 02120/09) <br /> 1 <br />