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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMITEXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> ✓_/TANK RETROFIT PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +---------------- --------------- ----------------- ------- ----- -------------------------------------+ <br /> EPA SITE # , PROJECT CONTACT & TELEPHONE # Scott Polston 925 551-7555 <br /> F ; FACILITY NAME Yosemite Arco PHONE # 925 551-7555 <br /> ' ------------------------------ --------------------------i <br /> C ; ADDRESS 1711 East Yosemite <br /> , <br /> ' I +-------------- ------------------------------------------------------------------------------------------------------� <br /> L ; CROSS STREET State Highway 120 <br /> ' I +-------- ----------------------------------------------------------------------------- ---I <br /> T OWNER/OPERATOR PHONE # <br /> Y Yosemite Arco (209)983-9140 <br /> ---+---------------- -------------------------------------------------+----- ----------------------' <br /> C ; CONTRACTOR NAME Gettler Ryan Inc. PHONE #925 551-7555 <br /> 0 +-------------------------------- ----------- ----- <br /> N ; CONTRACTOR ADDRESS 6747 Sierra Court,Suite J Dublin I CA LIC # 220793 CLASS a,b,c-10,ha2,c57,c61,d40 <br /> ' T +--------------------- --- -------------------------- ------------------ -------- <br /> R INSURER State Fund ; WORK.COMP.# 428-2004 <br /> , <br /> AI--------- -------------------------------------------------------+----------------------------------------I <br /> C OTHER INFORMATION <br /> 0 PHONE # 925 551-7555 <br /> PHONE # <br /> -----------------------------------r---------------------------------------------------------- <br /> TANK ID # ; TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> +---I II.. 'I ....I.I <br /> P <br /> L APPROVED 'APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ,I, RICA <br /> ATTACHMENT WITH CONDITIONS) <br /> N ; PLAN REVIEWERS NAME J�/ DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CO <br /> _OA HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE P FO F K FOR THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF C 0 <br /> Expeditor DATE <br /> APPLICANT'S SIGNATURE: TITLE Permit Exp <br /> ----------------------------------------------------------------------------------------------------------------------------------- <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> 6477terra Court,Suite J <br /> Name SCOtt POIS d ss 94566 Phone # 925 551-7555 <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />