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19255517888 Main Fax GETTLER RYAN INC '"^8:24 p.m. 05-03-2007 5/11 <br /> 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 PERMIT EXPIRES 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 REPAIRIRETROFIT <br /> *--------------------- --------------- ---------------------------------------------------------------------------------------- <br /> ; EPA SITE 4 CAL000250664 : PROJECT CONTACT A TELEPHONE (I LIDDYMCKENZIE 925 551.7555 <br /> ------------------------------------------------------------------------------------------------------------------------------- <br /> F FACILITY NAME ARCO 6020 : PHONE 0 q25 551.7655 ' <br /> A +------------------------------------------------------------------------------------------------------- ' <br /> C : ADDRESS 7711 E YOSEMITE AVE ' <br /> I +------------------------------------------------------------------------ ------------------------------------ ' <br /> L ; CROSS STREET ' <br /> I •--------------------`----------------------------------------------------------- <br /> T : OWNER/OPERATOR PHONE M ' <br /> Y <br /> --------------------------------------------------------------------------------------------------------------------------------- <br /> C : CONTRACTOR NAME Getuer Ryan Ina, : PHONE 0 925 551-7555 <br /> 0 +-------------------------------------------------------------------------------------------------- ' <br /> N : CONTRACTOR ADDRESS 6747 Sierra Court,Suite J Dublin : CA LIC 0 22079 : CLASS a;b,c-f O,Aax,c57,c61,d40 <br /> T +------------------------------------------------------------------------------------------------------------- , <br /> R : INSURER StateCompFurui : WORK-COMP-O 426.2007 <br /> A '----------------------------------------------------------- -+- <br /> C : OTHER INFORMATION <br /> T +------------------------------------------------------------------------------------+ <br /> ---------------------------------- <br /> 0 ; : PHONE # 925 551-7555 <br /> R +-----------------------------------------------------------------------------------`------`---- <br /> PHONE M <br /> „ --------------------------------------------------------------------------------- <br /> TANK ID 0 TANK SIZE : CHEMICALS STORED CURRENTLY/PREVIOUSLY : DATE UST INSTALLED <br /> 39- <br /> 3 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L : APPROVED ' ''APPROVED WIT CONDITION(S) DISAPPROVED <br /> A q ^ (SEE ATTR HMENT, <br /> TH CONDITIONS) C- <br /> N PLAN REVIEWERS NAME �, 1�Ltj (1 ,1y;, ,�(L�,� .I/1 DATE li <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, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF TH WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE Agent for Owner DATE 513/2007 <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 /> 6747 Sierra Court,Suite J <br /> Nance LIDDY MCKENZIE Address D-ID 946 Phone# 925 551-7555 <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />