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19255517888 Main Fax GETTLER RYAN INC 10:58:54 a.m. 10-05-2006 212 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT,PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT ------------ <br /> -= <br /> - --' ---+ <br /> +-----EPA SITE N ---- ------------ ---------- -- - <br /> 1_PROJECT CONTACT & TELEPHONE # Randy Brown - <br /> --- - <br /> ----------------------- <br /> PHONE # <br /> ' +-------------------------------- 1 209 8354 <br /> F I FACILITY NAME prop -------- ---------- <br /> C ADDRESS 3425 Tracy Blvd.Tracy --'---- <br /> - -------------- <br /> ----- <br /> 1 L ; CROSS STREET Clover ---------------------------' <br /> ------`-------- � PHONE # ' <br /> T I OWNEWPERATOR <br /> Y 1 #iP W@d Coed Product LLC ----- <br /> ---+------------------------ ------------ ------------------ ; PHONE If (925)551.7555 ------- <br /> C I CONTRACTOR NAME Gettler-R an Inc ----------------------------------------------------------------------- <br /> --------'Y-'----------------- <br /> o +-'---'----------- 1 CA LIC # 220793 CLASS A,B,HA7,511D40 <br /> N CONTRACTOR ADDRESS 6747 Sierra Court,Ste J -------------------' <br /> T +-------- I WORK.COMP.# 428-2007 <br /> R 1 INSURER State Comp Fund --------------------------------------------------- <br /> A <br /> ----------------- ' <br /> C 1 OTHER INFORMATION ---------------- ---------------------------------------- <br /> NFORMATION _________________ <br /> 0 +---------- -� <br /> ----------"-'------- -- PHONE If <br /> _------TANK SIZE --------------CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK ID # <br /> 39- <br /> T 39- <br /> A 39- <br /> N 1 39- <br /> 39- <br /> 1 <br /> 9- <br /> 39- — <br /> - 391 <br /> P111 � ,,,"" �",•,",IAPPROVEDI' 11 <br /> APPROVEDI WITH CONDITION'(S)II"II;DISAPPROVEDi111„"11II1I1 <br /> L I ATTACHMENT WITH CONDSTIONSI <br /> { N PLAN REVIEWERS NAME � <br /> _11 1111 � .� ,X11,III111;�11DATE'11i111111 : i 1:i1111;7,.� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT- OWNER OR LICENSED AGENT'S 7IEM LOYBANYRPERSON TIFIES INSUOCHLAWIMANNER•As TO <br /> TIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I IS >• D,I LL EN p,ERSONS SUBJECT' TO <br /> WORKER'S COMPENSATION LAWS OF CALIF RNIA." /✓� <br /> TITLEYI ATE <br /> APPLICANT'S SIGNATURE: -----__--_-+ <br /> +-------------------------------------- <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit <br /> it payment <br /> coverage per tank. If the party designated below is different than the permit app g• property <br /> owner,the party must acknowledge this responsibility for the billing by signature and date below. <br /> ess <br /> Name_ l.tnU Addr7 <br /> Phone# 9Z5 <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />