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9255517888 Line 12:43:03 12-17-2012 4/13 <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 /> TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> A F EPA Site# Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> C Facility NameARCO 6080 Phone# <br /> IAddress 85 E LOUISE AVE, LATHROP, CA 95330 <br /> 1TCrossStreet HARLAN <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> C Contractor NameGettler-Ryan Inc Phone# (925) 551-7555 <br /> N Contractor Address 220793 <br /> T 6747 SIERRA CT,SUITE J, DUBLIN,CA94568 CA Lic# CI3SSae,c,o.cs7.csvroo.w+z.„ic <br /> A insurer Travelers Property Casultv Co work comp# DTJUB78P41510 <br /> T ICC Technician's Name p 04/01/2013 <br /> T Alex Cordero Expiration Date <br /> R <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sLmp,91 leak detector,UDC 12,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved \Approved with conditions ❑ Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> � <br /> N Plan Reviewers Name Date I L{ Z• <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 AGENTS 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 CALIF Nl .” CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE OR RWNICH 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 Date12/17/2012 <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 /> ADDREss6747 SIERRA CT ITE J ,DOLIN 94568 <br /> SIGNATURE DATE / Z <br /> EH230038(revised 02/20/09) <br /> 1 <br /> Received Time Dec, 17. 2012 11 : 37AM No, 1880 <br />