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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER A E,3RD FLOOR <br /> STOCKTON,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 /> +--------------------- --------------- ---------------------- --------------------------------------------------------------+ <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # Scott Polston 925 551-7555 <br /> ------------------------------------------------------------------------------------------------------------------------------ <br /> F ; FACILITY NAME Mercedes Acosta Arco Station#0595 ; PHONE # 925 551-7555 <br /> ' A +-------- ------------------------------ ----------------------------------------------------------------------' <br /> C ; ADDRESS 6100 North Highway 99 <br /> ' I +---------------------------- -------------------------------------------------------------------------------------; <br /> L ; CROSS STREET East Hammer Lane <br /> ' I +------------------- -----------------------------' <br /> T ; OWNER/OPERATOR ; PHONE # <br /> Y Mercedes Acosta Arco Station#0595 (209)931.5976 <br /> ---+----- ------------ --------- ---------------+----------------------------------------' <br /> C ; CONTRACTOR NAME Gettler Ryan Inc. PHONE #925 551-7555 ' <br /> 0 +------------------ ------------ ------------------------------------------------------------------------; <br /> N ; CONTRACTOR ADDRESS 6747 Sierra Court,Suite J Dublin I CA LIC # 220793 : CLASS a,b,c-10,haz,c57,c61,d40 ; <br /> ' T +-------------------- ------------------------- <br /> R ; INSURER State Fund ; WORK.COMP.# 426-2004 <br /> A <br /> C ; OTHER INFORMATION <br /> ' -' ----------------------+------------------------------------- <br /> 0 PHONE # 925 551-7555 <br /> R +--------------------------------------------------- <br /> , PHONE # <br /> TANK ID # I'llll' I�' TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> 39- <br /> T ; 39- } <br /> A ; 39- <br /> N 39- <br /> K ; 39- <br /> 39- <br /> 39- <br /> + L " „""t„' """"" "';AP 1 ROV;1 1", V PROVED,WITH CONDITIO , 1 DISAPPROVED <br /> A (SEE TT HMENT WITH CONDITI <br /> N PLAN REVIEWERS NAME DATE I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE 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 COMPENSAT N LAWS OF CALIFOR CONTRACTOR' IRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE FO E O TH ORK ,R WH THI ERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF C ORN <br /> APPLICANT'S SIGNATURE: ITLE Permit Expeditor DATE z <br /> +----------------------------------------r— <br /> -------------- ---------------- -----------------------------------+ <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 /> i 6747 Sierra Court,Suite J <br /> Name SCOtt "ton Addr g Dubli 9456e Phone # 925 551-7555 <br /> Signatur <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />