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9255517899 Line 1ARTMENT <br /> 7a.m. 09-16-2010 8/11 <br /> NV <br /> tIRONATAL HEALTH UE <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,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 188 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 1Z TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> A <br /> C FacilityNamePG&E #6027038 Phone# (209) 337-8902 <br /> � Address 4040 WEST LANE, STOCKTON <br /> I Cross Street ENTERPRISE STREET <br /> T <br /> Y Owner/Operator ALEX STEELE Phone# (209} 337-8902 <br /> o Contractor Name Gettler-Ryan Inc Phone# (925) 551-7555 <br /> T Contractor Address 6747 SIERRA CT, SUITE J, DUBLIN, CA94568 CA Lic# 220793 Class;'ZCIOD,Cs7,c-shwa, <br /> A usurer Travelers Property Casualty Co of America work Camp# DTJUB7827P41510 <br /> T ICC Technician's Name Thomas Bishop Expiration Date 05/14/2012 <br /> R ICC Installer's Name Thomas Bishop Expiration Date 6/18/2012 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping Supp,91 leak eelec ,,UDC 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ><Approved with conditions ❑ Disapproved <br /> L S Attachment With Conditions) <br /> A <br /> N Plan Reviewers Nam Date �6,D7 li</ 70 <br /> APPLICANT MUST PERFORM AL RK 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 WHI H 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 C IFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THEW FOR TH MIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WO KER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature I Title 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 TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE DATE <br /> EH230038(revised 02120/09) <br /> 1 <br />