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0 <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 <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Randy Brown 916-826-6828 <br />A <br />C <br />Facility Name Aro 2133 <br />Phone # 209-941-2694 <br />� <br />Address 2903 Benjamin Host Drive, Stockton, Ca. 95207 <br />TCross <br />Street Plymouth <br />Y <br />Owner/Operator BP West Coast Products LLC Scott Listar <br />Phone # 530-621-0770 <br />o <br />Contractor Name Gettler-Ryan Inc <br />Phone # 925-551-7555 <br />N <br />T <br />Contractor Address 6747 Sierra Court Suite J, Dublin, CA. 94568 <br />CA Lic # 220793 Class Attached <br />R <br />A <br />InsurerAcord <br />Work Comp # DTJUB7827P41510 <br />T <br />ICC Technician's Name Chris Bishop <br />Expiration Date May, 14 2012 <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />91 spill fill bucket <br />10,000 gallon <br />Gas 91 <br />4/6/1999 <br />T <br />A <br />N <br />K <br />P <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />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." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF T RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Service Manager April 11, 2011 <br />Applicant's Signature Title Date <br />v " BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the billing by signature and date below. <br />NAME Randy Brown TITLE Service Manager PHONE # 916-826-6828 <br />ADDRESS 674�rra Court Suite J, Dublin, Ca. 94568 <br />SIGNATU <br />EH230038 (revised 07/22/10) <br />2 <br />April 11, 2011 <br />