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SANJOAQUIN Environmental Health Department <br /> COUNTY <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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Merlin Bowen 925 . 551 -7555 <br /> A <br /> c Facility Name ARCO #2186 Phone # 209 , 941 -2694 <br /> I <br /> L Address 3212 N . California <br /> I Cross Street E Alpine Avenue <br /> T <br /> Y Owner/OperatorBP/ARCO West Coast Products LLC Phone # 847 . 340-3092 <br /> o Contractor NameGettler-Ryan , Inc . Phone # 925 , 551 , 7555 <br /> N <br /> T Contractor Address 6805 Sierra Court , Suite G CA Lic # Class <br /> A Insurer Zurich American Insurance Company Work Comp # WC090463403 <br /> T ICC Technician 's NameMatthew Campbell Expiration Date 3/31 /2024 <br /> R ICC Installer's Name John Li Expiration Date 2/03/2024 <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 manway/spill bucket/dop tube 20 , 000 87 gasoline fuel <br /> A manway/spill bucket/dop tube 10 , 000 91 gasoline fuel /split tank <br /> N <br /> K manway/spill bucket/dop tube 12 , 000 diesel fuel/split tank <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A r� <br /> N Plan Reviewers Name L� Date 2T L <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 TO <br /> 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 SignaturePermit Tech_ ( Title Date 1 / 18/2023 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e . g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Merlin Bowen (agent for contractor) TITLE Permit Tech PHONE # 925 . 551 -7555 <br /> ADDRESS 6805 Sierra Court , Suite G , Dublin , CA 94568 <br /> SIGNATURE DATE 1 / 18/2023 <br /> 2of6 <br />