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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HLTH DEPARTMENT <br /> 304 E WEBER AVE,30.0 FLOOR <br /> STOCKTO ,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> ; EPA SITE # PROJECT CONTACT & TELEPHONE # Scott Polslon Ins 551-7555 ` <br /> +______________ _________________-____________� <br /> F ; FACILITY NAME Arco Service Station#9600 -- _ _ - -_ 1 PHONE # 925 551-7555 <br /> A +____________________________________________________________________________________________________________________________� <br /> C I ADDRESS 7250 North Wilson Way <br /> I +_____________________________________________________________________________________________________________________________� <br /> L ; CROSS STREET <br /> I +______________________________________________________________________________________ __ ________________________________� <br /> T OWNER/OPERATOR PHONE # <br /> Y Arco Semice Steecn#9000 <br /> ___+____________________________________________________________________________________+___________________________________-___' <br /> C ; CONTRACTOR NAME Gettler Ryan Inc. PHONE #925 5514555 <br /> o +--------------------------- _________________________________ <br /> , CLASS a,b,c-10,haz,c57,c61,d40 <br /> N CONTRACTOR-------- ADD--ss ---- Sierra Cour-,Suite J Dublin cA Lm # 220793 <br /> R INSURER State Fund ; WORK.COMP.# 426.2004 <br /> A _______________________________________� <br /> C OTHER INFORMATION ___________________________________ <br /> 0 ---- _ - PHONE # 925 551-7555 <br /> R _______________ __ PHONE # <br /> TANK ID # � "11f TANK SIZE t <br /> 'i CNSMI GALS STORED CURRENTLY/PREVIOUSLY ', DATE UST INSTALLHD ' <br /> 39- <br /> T 39- <br /> A 39- <br /> N ; 39- <br /> K ; 39- <br /> 39- <br /> 39- <br /> L ; APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A wA T JTTACHMSNT WITH CONDITIONS) <br /> N I PLAN REVIEWERS NAME ,I'GLLsfi 1L.1 R4RrV� DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATS LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATIO WS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PH RMANCE OF W FOR WHICH THIS PE T IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPBNSATION LAWS OF CALI IA." <br /> APPLICANT'S SIGNATURE: T LE Permit Expeditor DATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> 6747 Sierra Court,Suite J <br /> Name SCOtt POISt dr s D hn 94566 Phone # 925 551-7555 <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> i <br />