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9255517888 Line 1 20:00 12-08-2015 419 <br /> w - <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY DEC 08 2ci . <br /> 600 East Main Street,Stockton, California 95202 ENVIRCNMI NTAi <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 I-4f:AIT�-r ncD,qeaTAeCfvT <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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# CAL000225724 Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> A <br /> C Facility NameARCO-2186 Phone# (209) 941-2694 <br /> 1 Address 3212 N CALIFORNIA, STOCKTON, CA 95204 _ <br /> L <br /> T <br /> Cross Street <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> C Contractor Name Gettier-Ryan Inc Phone# (925) 551-7555 <br /> T Contractor Address 6747 SIERRA CT,SUITE J,DUBLIN,CA94566 CA Lic# 220793 ClaSsne,c,o,cn.ost,a.a.wanc <br /> A Insurer STATE COMPENSATION INS FUND Work Comp# 9051229-16 <br /> C ICC Technician's Name P 08/03/2016 <br /> T Chris Reeves Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector.UDC 12,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approvedt Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A - <br /> N Plan Reviewers Name O 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 AGENTS 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 CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 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 Date12/08/2015 <br /> 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 Manager -PHONE#925.551.7555 <br /> ADDREss6805 SIERRA CT, SUITE G, DUBLIN, 94568 <br /> SIGNATURE DATE <br /> EH230038(revised 02/20109) <br /> 1 <br />