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19255517888 Main Fax • 13ETTIER RYAN INC 1626 p.m. 03-05-2007 4/12 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE.3Fc FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: TANK RETROFIT—PIPING REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT------------------- ------------------- + ____________ _______ _.l ,AAAA__ + PROJECT CONTACT F TELEPHONE k IIDDY MCNENLE aM 331-)555 ' AAAA___________ CAUX) EPA SITE k ----- ---- _------------------------ ---- ____________________ _________________________________________________________________________ ♦_FACILITY_ PHONE k 925 P ---555 FACILITY NAME ------ - _________AAAA___ CADDRESS 1250 N WILSON WAY ____________________________________________; I ______________ I L I CRUISE STREET _ -- _ _ ______________________________________-------------------------------------------- I ____ __________________________AAAA___ I --------------------------- ; PHONE # T ; OWNER/OPERATOR SIP WEST COST PRODUCTS ___ Y _____________ _HONE_______________ AAAA______________________ __________________________________ _ C ; CONTRACTOR NAME Gettler Ryan Inc. ----- k -- 5N-555 o +_CONT_____ __________________________________________________________ LIC k 220793 AAAA__—__;_CLhns a,b,c-10,ha:,c57,c51,d40 H CONTRACTOR ADDRESS 5747 S--re COW-,Suite Dublin _________________________ ___________________�, T t_________________________________________________________________________------------------------------------------------- : __ R I INSURER State Camp Fund WORR.COMP.k 42a-200] A I_____________________________________ _ __________AAAA_ ___________________+______________—-_____________________ C i OTHER INFORMATION ------------------------------------------------------ --------------------------------------------- PHONE k 925 551-7555 ' o ' _AAAA__ AAAA_ _________________________________, _ ___________________________I __________ TORE_____ ___________ ' ----'-'--TANK SIZE CIDHIGALE STORES) CURRENTLY/PRBVIOO6LY DATE UST IN9TALLID AAAA___ TAMC ID # � •" 39- T 39- A 39- N 39- K 39- 39- 39- I L I I 77 „FFTF F7 ,. P L " '1 1' ' _'APPROVED APPROVXD WITH CONDITION(S) _ DISAPPROVED A // ( E ATTACHMENT WITH cORDITIONS) DATE N 'Idllti 1;;;" , ,. ,,...,,, ��. � .... �i ILII, 3 "171 PLAN ReVI8WER5 NAME .. � ' APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN MONTY ORDINANCES, STATE LAWS, AND ROLES AND REGULATIONS OF ERN JOAQUIN COUNTY, ENVIRONMENTAL MHALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING, "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AE TO BECOME SQEJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: °I CERTIFY THAT IN THE PERFORMANCE OF WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFO A. A 1 A Agent for Owner DATE 315/2007 APPLICANT'S SIGNATURE: TITLE + . .AAAA______________________ t________________ BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. 6747 Slerra Court,Suite J Name LIDDY MCKE ZI Address DObun 9d Phone.. 925 551-7555 Signature EH230038 (revised 1/31/02) i