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9255517888 Line 111T, a.m. 06-01-2016 4,111 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY � � <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 JUN 01 2016 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING R&P/ PRrPBiR�IIT' <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> 1Z 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 /> I <br /> T Cross Street E ALPINE AVENUE <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> C Contractor Name Gettler-Ryan Inc Phone# (925) 551-7555 <br /> N Contractor Address 6805 SIERRA CT,SUITE G,DUBLIN,CA94568 CA Lic# 220793 ClaSSve.Cm.C5 c.euoao,HAZ,MC <br /> A Insurer State Compensation Ins Fund Work Comp# 9051229-3 <br /> T ICC Technician's Name ELOD10 SANCHEZ Expiration Date 09/10/2015 <br /> R ICC 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.UCC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions C Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name �1;� l,�eR,{ 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,l SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNI ." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR ICH THISRBRVIT 15 ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Applicant's Signature '��krice AGENT FOR OWNER Date6/01/2016 <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 TITLEProiect Manaqer PHONE 4925,551.7555 <br /> ADDREss6805 SIERRA CT SUITE G LIN 94568 <br /> SIGNATURE DATE <br /> EH230D38(revised 02/2010 <br /> 1 <br />