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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> 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# Randy Brown 916-826-6828 <br /> A <br /> C Facility Name West Valley Chevron Phone# 209-836-3464 <br /> � Address 2615 West Grant Line Road, Tracy, Ca. <br /> I Cross Street <br /> T <br /> Y Owner/Operator West Valley Chevron Phone#408-636-6651 <br /> o Contractor Name Gettler-Ryan Inc Phone# 925-551-7555 <br /> N Contractor Address 6747 Sierra Court Suite J, Dublin, CA. 94568 CA Lic# 220793 Class Attached <br /> T <br /> R <br /> A InsurerAcord Work Comp#DTJUB7827P41512 <br /> T ICC Technician's Name Chris Bishop Expiration Date May 14, 2012 <br /> R ICC Installer's Name Chris Bishop Expiration Date June 18, 2012 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T 87 Piping Sump Unknown 87 Gas Unknown <br /> A 91 Piping Sump Unknown 91 Gas Unknown <br /> N <br /> K Diesel Piping Sump Unknown Diesel Unknown <br /> P ❑ Approved �Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date�� �7� <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 CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant'sSignatur Title Service Manager Date April, 19, 2012 <br /> BILLING INFORMATION: <br /> Indicate the responsible parry to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> NAME Randy Brown TITLE Service Manager PHONE# 916-826-6828 <br /> ADDRESS 6747 Si rra Court Suite J, Dublin, Ca. 94568 <br /> SIGNATUR DATE April 19, 2012 <br /> EH230038(revised 07/22/10) <br /> 2 <br />