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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 n PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT C COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone If MERLIN BOWEN 925.551.7555 <br /> C Facility Name ARCO SS#7049 Phone#209.934.3676 <br /> 1 <br /> L Address600 E KETTLEMAN LANE,LODI,CA 95240 <br /> T Cross Street S CHEROKEEN LANE <br /> Y Owner/OpelatorBP ARCO WEST COAST PRODUCTS LLC Phone#530A70.6133 <br /> o Contractor Name Gettier Ryan Inc. Phone#925.551.7555 <br /> N Contractor Address6805 Sierra Court, Sulte G,SUITE G CA Lic#220793 ClassA/B/C61-D40/CI <br /> T <br /> A InsurerState Compensation Ins Fund Work Comp#9051229 <br /> C <br /> T ICC Technician's Name TIM PERRY Expiration Date 3/25/2020 <br /> D <br /> R ICC Installers NameTIM PERRY Expiration Date 3/25/2020 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> p•.sT Pv�s aaP.sI w1,aa•aor,uoc 1rz,x 1 Installed <br /> T FILL BUCKET/DROP TUBE 10,000 GASOLINE UNKNOWN <br /> A <br /> N <br /> K <br /> A IN <br /> P �. Approved roved with conditions Disa roV <br /> L (Sde Attachment V+hlh Conditions) <br /> A yy <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING "I CERTIFY THAT IN <br /> L�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 /> iWORKERS COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. "I CERTIFY <br /> ITHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> F CALIFORNIA." <br /> Applicant's Signatum�, ,�/h TIee 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 /> NAMELiddy McKenzie TITLEProject Manager PHONE#925.551.7555 <br /> ADDRESS6805 SIERRA CT, SUITE G, DUBLIN, 94568 r� <br /> SIGNATURE O DATE <br /> ER230038(revised 47-2014) <br /> 2 <br />