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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#MERLIN BOWEN 925.551.7555 <br /> C Facility Name ARCO SS#5450 Phone#209.462.1617 <br /> I Address 1617 W . FREMONT STREET <br /> L <br /> T Cross Street N. PERSHING AVENUE <br /> Y Owner/Operator BP ARCO WEST COAST PRODUCTS LLC Phone#530.470.6133 <br /> C Contractor Name Gettler Ryan Inc. Phone#925.551.7555 <br /> O <br /> N Contractor Address 6805 Sierra Court, Suite G, SUITE G CA Lic#220793 Class A/B/C61-D40/CIC <br /> T <br /> A Insurer State Compensation Ins Fund Work Comp#9051229-3 <br /> C <br /> T ICC Technician's Name TIM PERRY Expiration Date 3/22/2020 <br /> Q <br /> R ICC Installer's Name TIM PERRY Expiration Date 3/22/2020 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T DROP TUBE, BALL FLOAT CAGE 12,000 GASOLINE UNKNOWN <br /> A DROP TUBE, BALL FLOAT CAGE 12,000 GASOLINE UNKNOWN <br /> N <br /> K DROP TUBE, BALL FLOAT CAGE 12,000 GASOLINE UNKNOWN <br /> GASOLINE <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L (S chment With Conditions) <br /> N Plan Reviewers Name Date `11bk A� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANC TH 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALI NIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THEW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Tibe AGENT FOR OWNER Date 9/05/2018 <br /> BILLING INFORMATION: <br /> Indicate the responsiblea to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated ow 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 6805 SIERRA CT, S G LIN, 94568 <br /> SIGNATURE DATE <br /> EH230038(revised 07-17-2014) <br /> 2 <br />