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ENVIRONMENTAL HEALTH DEPARTMENTEC 09 201 <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 ENVIR�� <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> A <br /> C Facility NameARCO 2186 Phone# <br /> I Address 3212 N CALIFORNIA STREET <br /> L <br /> Cross street <br /> T E ALPINE AVENUE <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> c Contractor NameGettler-Ryan Inc Phone# (925) 551-7555 <br /> T Contractor Address 6805 SIERRA CT, SUITE G, DUBLIN,CA94568 CA Lic# 220793 CIasS4.s.C10.C57,C-61040,HAZ,HIC <br /> A Insurer State Compensation Ins Fund Work comp# 9051229-3 <br /> T ICC Technician's Name Wesley Morrison Expiration Date 03/17/2017 <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc) Installed <br /> T SUPREME/REGULAR 10,000/12,0fi SFL/d GASOLINE <br /> N REGULAR 20,000 GASOLINE <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name ti Date <br /> APPLICANT MUST PERFORM ALL WORK 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 WHICH 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 CALIF A." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK ICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title AGENT FOR OWNER Date12/0'/2015 <br /> J 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 /> NAMELiddy McKenzie TITLE Project Manaqer PHONE#925.551.7555 <br /> ADDREss6805 SIERRA CT SUITE G LIN 68 ) <br /> SIGNATURE DATE <br /> EH230038(revised 02/ 9� <br /> 1 <br />