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9255517888 Line 09:26:10 04-20-2015 4/10 <br /> ENVIRONMENTAL HEALTH DEPA ptft1VE <br /> SAN JOAQUIN COUNTY APR 2 0 2015 <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIRONMENTAL <br /> 1 I{^G11 TIJ rl rr)�,�Tl Ar.'�IT <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 /> 1Z TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> A <br /> Facility Name8363464 Phone# (408) 636-6651 <br /> Address 2615 West Grantline Road, Tracy <br /> TCross Street <br /> Y Owner/Operator West Valley Chevron Phone# <br /> O Contractor Name <br /> Q Gettler-Ryan Inc Phone# (925) 551-7555 <br /> T Contractor Address 6805 SIERRA CT,SUITE G,DUBLIN,CA94568 CA Lic# 220793 CIaSSk.e,c0.W.C4vo0.lwec <br /> A Insurer State Compensation Ins Fund Work Comp# 9051229-3 <br /> C ICC Technician's Name y p 03/17/2017 <br /> T Wesle Morrison Expiration Date <br /> QICC installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 Ieax detector,UDC 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disa proved <br /> L (See achment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> —L, , d <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COONRDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEAD PARTMENT.OWNER OR LICENSED ENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR%;LTH 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 C FORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WO 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 Date04/20/2015 <br /> BILLING INFORMATION: <br /> Indicate th onsible 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 UBLIN 94568 <br /> SIGNATURE DATE (] <br /> EH230038(revised 02/20 <br /> 1 <br /> Received Time Apr, 20, 2015 9 : 14AM No- 8549 <br />