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19255517888 Main Fax • <br /> GETTLER RYAN INC 4:35 a.m. 09-25-2007 5111 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton, California 95202 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYSFROMTHE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ,, <br /> STANK RETROFIT YJPIPING REPAIR/RETROFIT Lluoc REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> FacilityName <br /> TOKAY SHELL Phone# <br /> I L Address 420 W KETTLEMAN LN, LODI, CA 95240 <br /> 1 Cross Street S I FF AVE <br /> Y Owner/Operator Fouilon Enterprises LLC / Shell Oil Products Phone# <br /> DContractor Name Gettler-Ryan Inc Phone# (925) 551-7555 <br /> OClass •.e.c'O,Cs,ca+m40., HIC <br /> N Contractor Address 6747 SIERRA CT, SUITE J,DUBLIN,CA94566 CA LIC# 220793 <br /> T work Comp# 238-0003058 <br /> A <br /> R Insurer STATE COMPENSATION INS FUND <br /> Expiration Date 06/28/2009 <br /> G ICC Technician's Certification Number 5254810-UT <br /> TExpiration Date 06/28/2009 <br /> R ICC Installer's Certification Number 5254810-UI <br /> Tank Size Chemicals Stored Date UST Installed <br /> Tank ID# Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P <br /> []Approved Approved with conditions ❑Disapproved <br /> L ( elMtachment With Conditions) <br /> A <br /> N Plan Reviewers Name U Q Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> LOWING: "I CERTIFY THAT IN <br /> THE PEIRFORMANCE OFITHHE WORK FOR WHICH EH SRP RMT IS SSUED,RI SHALL NOT EMPLOY ANY LICENSED AGENT'S NPERSON IN SUCH A MANNATURE CERTIFIES THE ER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." NTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHI T PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Sgnature Tine AGENT FOR OWNER Date 9124/2007 <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 <br /> Liddy McKenzie TITLE Project Manager PHONE ti 925.551.7555 <br /> ADDRESS 6747 SIERRA CT IT d DUBLIN 94568 <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br /> 1 <br />