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9255517888 Line 13:02:44 03-10-2014 4/17 <br /> 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 RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> 14 TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> A <br /> C Facility NameARCO 6080 Phone# <br /> I Address 85 E LOUISE AVE, LATHROP, CA 95330 <br /> Cross Street HARLAN <br /> T <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> o Contractor Name Gettler-Ryan Inc Phone# (925) 551-7555 <br /> T Contractor Address 6805 SIERRA CT,SUITE G,DUBLIN,CA94568 CA Lic# 220793 CIas&e.c,o.cn.c-6„t»o,wam,c <br /> A Insurer STATE FUND work Comp# 9051229-13 <br /> C ICC Technician's Name P 12/6/2014 <br /> T Chris Nicolas Expiration Date <br /> oICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 12,etc.) y installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ElDisapproved 91 <br /> L (S a Attac�ment With Conditions) <br /> A <br /> N Plan Reviewers Name Date "J�7-4`t <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 OFTHE 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 Dat,,03/10/2014 <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 /> ADDRESs6805 SIERRA CT SUITE G UBLIN 94568 !� <br /> SIGNATURE DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br /> Received Time Mar, 10. 2014 12: 53PM No, 5384 <br />