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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 IND;CATE PERMIT TYPE BELOW <br /> 0 TANK RETROFIT ❑PIPING REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT 0 COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact 8,Telephone#MERLIN BOWEN 925.551.7555 <br /> C Facility Name ARCO SS#7049 Phone#209.934.3676 <br /> I Address 800 E KETTLEMAN LANE,LODI,CA 95240 <br /> L <br /> T Cross Street S CHEROKEEN LANE <br /> Y Owner/OperatorBP ARCO WEST COAST PRODUCTS LLC Phone#530.470.6133 <br /> C Contractor Name Gettler Ryan Inc. Phone#925.551,7555 <br /> 0 <br /> N <br /> T Contractor Address 6805 Sierra Court,Suite G,SUITE G CA Lic#220793 GlassA/B/Ct3i-D40/CI <br /> A InsurerState Compensation Ins Fund Work Comp#9051229 <br /> C <br /> T ICC Technician's NameTIM PERRY Expiration Date 3/25/2020 <br /> o <br /> R ICC Installer's NameTIM PERRY Expiration Date 3/25/2020 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (I e.07 piping sump,81 leek delecW.UDC Irl.etc) Installed <br /> T FILL BUCKET/DROP TUBE 10,000 GASOLINE UNKNOWN <br /> A <br /> N <br /> K <br /> P El Approved pproved with conditions p rove <br /> Disa u <br /> ❑ <br /> L ( e Attachment With Conditions) <br /> A ii <br /> N Pian Reviewers Name , �'`��) Date , 1 <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 "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 /> WORKERS 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 /> pplicant'sSignatura �- Tide AGENT FOR OWNER Data / <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 /> ADDRESS6805 SIERRA CT, SUITE G, DUBLIN, 94568 <br /> SIGNATURE DATE z01 <br /> EH230038(revised 17-2014) <br /> 2 <br />