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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 9202 <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# CAL000225724 Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> A <br /> C Facility NameARCO-2186 Phone# (209) 941-2694 <br /> I <br /> L Address 3212 N CALIFORNIA, STOCKTON, CA 95204 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator BP West Coast Products LLC Phone# (360) 371-1500 <br /> o contractor NameGettler-Ryan Inc Phone# (925) 551-7555 <br /> T Contractor Address 6805 SIERRA CT,SUITE G,DUBLIN,CA94568 CA Lic# 220793 clas&oe Clo.C57,C-61040,HAz.H1C <br /> A Insurer STATE COMPENSATION INS FUND work Comp# 9051229-13 <br /> T ICC Technician's Name Chris Reeves Expiration Date <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 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P I Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date (///h <br /> APPLICANT MUST PERFORM ALL W IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMEN HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WO K 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 10"/ ' �l Title AGENT FOR OWNER Date11/05/2013 <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 /> NAMEMerlin Bowen TITLE Permit Tech PHONE#925.551.7555 <br /> ADDREss6805 SIERRA CCT, SUITE G, DUBLIN, 94568 <br /> SIGNATURE `�rZ/L-�L '%�.i� DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />