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,9255517888 Line 13:03:38 07-15-2013 4/12 <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 /> 1Z 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 <br /> L Address 85 E LOUISE AVE, LATHROP, CA 95330 <br /> I Cross Street HARLAN <br /> T <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> C Contractor NameGettler-Ryan Inc Phone# (925)551-7555 <br /> T Contractor Address 6747 SIERRA CT, SUITE J, DUBLIN, CA94JJ CA Lic# 220793 ClassA,B,C10,C57,6 <br /> R Insurer <br /> A Travelers Property Casulty Co Work Comp# DTJUB78P41510 <br /> T ICC Technician's Name Wes Morrison Expiration Date 03/19/2014 <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1Q etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Q Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <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 <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CO ACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF Ty WORK FOR WHI <br /> OF CALIFORNIA." PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> Applicant's Signature Tide AGENT FOR OWNER Date7/15/2013 <br /> BILLING INFORMATION.- <br /> Indicate <br /> NFORMATION;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 /> NAMELiddy McKenzie TITLE Project Manager PHONE#925.551.7555 <br /> ADDRESS6747 SIERRA CT, SUITE , UBLIN, 94568 <br /> SIGNATURE DATE 7/15/2013 <br /> EH230038(revised 02/20!09) <br /> 1 <br /> RecE ved 1Irr�e Jul, 15. 2010) 12 . 56FM No. 3591 <br />