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9255517888 Line 0- 13:53 a.m. 10-27-2009 4/11 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor, Stockton,California 95202 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# CAL000258664 Project Contact&Telephone# Liddv McKenzie (925.551.7555) <br /> A <br /> c Facility Name ARCO 6020 Phone# (209) 823-4715 <br /> I <br /> L Address 1711 E YOSEMITE AVE, MANTECA, CA 95336 <br /> I <br /> T Cross Street HWY 99 <br /> y Owner/Operator BP West Coast Products LLC Phone# <br /> 0Contractor Name Gettler-Ryan Inc Phone# (925) 551-7555 <br /> 0 <br /> T Contractor Address 6747 SIERRA CT,SUITE J,DUBLIN,CA94568 CA Lic# 220793 Class AB.CI6,G67,U61 DaD.HA2 HIC <br /> A Insurer STATE COMPENSATION INS FUND Work Comp# 238-0003058 <br /> T ICC Technician's Certification Number 5252315-UT Expiration Date 06/06/2010 <br /> R ICC Installer's Certification Number 5252315-U I Expiration Date 06/06/2010 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved RApproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name 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,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE W K F HICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title AGENT FOR OWNER Date 10/27/2009 <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 /> NAME Liddy McKenzie TITLE Project Manaqer PHONE# 925.551.7555 <br /> ADDRESS 6747 SIERRA CTS TE J D IN 94568 <br /> SIGNATURE <br /> EH230038(revised 8/8/46) <br /> 1 <br />