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9255517888 Line 11:01:20 03-20-2013 4/10 <br /> ENVIRONMENTAL HEALTH DEPARTMENTJ`l <br /> SAN JOAQUIN COUNTY MAR 2 0 2013 <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIcIONMENTA.LHEALTH <br /> PERWT/6'ERy'ICIES <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 /> 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 /> 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 /> o Contractor Name G ettler-Ryan Inc Phone# <br /> (925) 551-7555 <br /> N Contractor Address 220793 <br /> T 6747 SIERRA CT,SUITE J, DUBLIN,CA94568 CA LIC# Cl2SSos.cio.c57,covo4o.rwz.wc <br /> A Insurer Travelers Property Casulty Co work comp# DTJUB78P41510 <br /> CICC Technician's Name <br /> T Chris Nicolas Expiration Date 12/6/2014 <br /> RICC 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 1/2,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> (Se Att <br /> A achment With Conditions) <br /> N Plan Reviewers Name Date_ L'_ <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 ALIFORNIA" RACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF A RK FO IC IS IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Tille AGENT FOR OWNER Date03/20/2013 <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 /> NAMELiddy McKenzie TITLE Project Manaqer PHONE 425.551.7555 <br /> ADDRESs6747 SIERRA CT ITE DUBLIN 94568 <br /> SIGNATURE DATE z� <br /> EH230038(revised 02/20/09) <br /> 1 <br /> Received Time Mar. 20, 2013 10 :54AM No- 2602 <br />