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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 REPAIR/RETROFIT <br /> +--------------------- --------------- ---------------------- --------------------------------------------------------------+ <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # Scott Polston 925 551-7555 <br /> F FACILITY NAME ARCO <br /> A --------------------------------------------------ANNA--- PHONE # 92$--------551.7555--ANNA----- <br /> : FACILE---NAME--------ANNA--ANNA- <br /> -------------------------------------------------------- ------------------ ---- <br /> C I ADDRESS 3425 TRACY BLVD <br /> ' I +----------------------------------------------------------------------------------------------------------ANNA---ANNA- <br /> -------' <br /> L ; CROSS STREET CLOVER <br /> I +------------------------------------------------------------------------------------_ ____------------------------------ <br /> T OWNER/OPERATOR PHONE # <br /> Y ARCO <br /> ---+------------------------------------------------------------------------------------+----------------------------------------I <br /> C ; CONTRACTOR NAMEGettler R all In C. 1 PHONE #925 551-7555 <br /> 0 +--------------------------y-------------------------------------------------------- -----------------------------------I <br /> N ; CONTRACTOR ADDRESS 6747 Sierra Court,Suite J Dublin , CA LIC # 220793 : CLASS a,b,c-10,haz,c57,c61,d40 <br /> T +------------------------------------------------------------------------------------WORK.COMP.#---------------------------- <br /> R INSURER State Fund 426-2004 <br /> A '---------------------------------------------------------------------------------+--------------------------------------I <br /> C OTHER INFORMATION <br /> -------------------------------------------------------------- I <br /> +--ANNA------ <br /> ---------------------------- <br /> T +-------------ANNA-- ; PHONE # 925 551-7555 <br /> D <br /> R +----------------------------------------------------------------ANNA----ANNA--ANNA-- <br /> +-----------------------------------ANNA-� <br /> PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> ;;IIIIIIIIII III <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAMDATE <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 SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <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 IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." C j <br /> APPLICANT'S SIGNATURE: �� TITLE Permit Expeditor DATE / �b <br /> +---------------------------------------------ANNA----------ANNA——------------------------------------------------------ <br /> --------+ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> 6747 Sierra Court,Suite J <br /> Name SCOtt POISton Address Dublin 94568 Phone # 925 551-7555 <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />