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EIVED <br /> ENVIRONMENTAL HEALTH DEPA ENT <br /> SAN JOAQUIN COUNTY FEB 0 4 2022 <br /> 600 East Main Street, Stockton , California 952VIRONMENTAL HEALTH <br /> Telephone : (209) 468 -3420 Fax : (209) 468m344* DEPARTMENT <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 /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT COLD START/ EVR UPGRADE <br /> F EPA Site # 178 - 14 - 019 Project Contact & Telephone # Liddy McKenzie ( 925 . 551 . 7555 ) <br /> C Facility Name RAMOS OIL COMPANY Phone # 800 . 477 . 7266 <br /> I <br /> L Address 10842 SOUTH HARLAN ROAD <br /> Cross Street ROTH ROAD <br /> T <br /> Y owner/Operator RAMOS OIL COMPANY Phone # 800 . 477 . 7266 <br /> C Contractor Name GETTLER- RYAN , INC Phone # ( 925 ) 551 . 7555 <br /> O <br /> T Contractor Address 6805 SIERRA COURT , SUITE G , DUBLIN , CA 94568 CA Lic # 220793 CIaSSA, B , C10,C-61 /D40, HAZ, <br /> A Insurer Zurice Amer Ins Co work Comp # WC090463402 <br /> T ICC Technician ' s Name p <br /> T Expiration Date <br /> Q ICC Installer' s Name p <br /> R Expiration Date <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 DIESEL TANK DIESEL <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S e Attachment With Conditions) <br /> A _ <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 WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S 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 /> Applicant 's Signature Title AGENT FOR OWNER Date 02 /04/2022 <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 /> NAMEMERLIN BOWEN TITLE PERMIT TECHNICIAN PHONE #925 . 551 . 7555 <br /> ADDREss6805 SIERRA CT SUITE G DUBLIN 94568 <br /> SIGNATURE /D 44 DATE 02 /04/2022 <br /> EH230038 (revised 02/20/09) <br /> 1 <br />