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19255517888 Main Fax GETTLER RYAN INC 10 P.M. 01-26-2007 5/11 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,33D FLOOR STOCKTON.CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 9D DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: TANK RETROFIT _PIPING REPAR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT ._____ _____________________________________________________________________ ________________________ y I ; EPA SITE a : PROJECT CONTACT 6 TELEPHONE If LIUDY MCKENZIErb 631.1335 y_____________________________________________________________________________ ______________ _____ _________________________; F FACILITY NAME ARCO PRO" a 925 SSI.7665 Ay___ ___________________________________________ ________________________________________________- ; C ADDRESS 1259 N FAL90N Iy_____________________________________________________________________________________________ _______________________________; L CROSS STREET 1.5 Iy_____________________________________________________________________________________________________________________________; T OWNER/OPERATOR PRONG 3 Y ; ARCO _____________ __________________________ _____________________-_______________________________-____-___; I C I CONTRACTOR NAME Gettler Ryan Inc. ; PHONE 9 92S a61-7665 N I CONTRACTOR ADDRESS 6747 Sierra Court,Suite Dublin : CA LIC a 220793 : CWISs a,b,c•10,hw,eS7,961,d40 Ta_____________________________________________________________________________________________________________________________� R ; INSURER State Comp Fund : WORK.COMP.# 428.2007 A _________________________________________________________ ________________y________________________________________I C ; OTHER INFORMATION Ty_______________________________________________________ __ __ ______________________y________________________________________; 0 ; I PHONE a 925 551.7555 IRy_____________________________________________________________________________________________________________________________; , :_PHONE_# ------------------------------------------------------ TANK ID a TANK SIZE CHEMICALS STORED CURRENTLY/FREVIOUSLY DATE UST INSTALLED 39- 1 39- A 1 39- N 39- I K 39. 39. 39- 1 P L "APPROVED '��APPROVED KITH CONDITION(6) DISAPPROVEO�� A I (SEE ATTACHMENT WITH CONDITIONS) N I PLAN REVIENBRS MAH E�',(1/,T`A^Q DATE 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH 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 SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO SECURE SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CRRTIFY THAT IN THE PERFORMANCE 0 THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNI APPLICANT'S SIONATURB: TITLE Permit Expeditor DATE v .( y______-------------------------- __________________ ______________ ___________ ______________y BILLING INFORMATION: Indicate the responsible parry 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 Siem Court,Suite J Name LIDDY MCKENZIE Add r ss Dublin 94%8 Phone# 925 551-7555 Signature EH230038 (revised 1/31/02) i