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ENVIRONMENTAL HEALTH DEPARTMENT BCE #13418 <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 ZCOLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # M. Alexia Inigues / (425) 251-6222 <br />A <br />C <br />Facility Name ARCO Facility No. 2093 <br />Phone# (209) 334-3678 <br />1 <br />L <br />Address 3425 Tracy Boulevard, Tracy, CA 95376 <br />TCross <br />Street W. Clover Street <br />Y <br />Owner/Operator BP West Coast Products LLC <br />Phone# (510) 432-8397 <br />C <br />O <br />Contractor Name Gettler-Ryan Inc. <br />Phone# 925-551-7565 <br />N <br />T <br />Contractor Address 6747 Sierra Court Suite J <br />CA Lic # Class <br />220793 C57,B,D40,A,C <br />R <br />A <br />Insurer State Compensation Insurance Fund <br />Work Com # <br />P 238-0003058 <br />C <br />r <br />ICC Technician's Certification Number 5252010 -UT <br />Expiration Date <br />RICC <br />Installer's Certification Number 5250452 -UT <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Date UST Installed <br />Currently/Previously <br />T <br />A <br />N <br />K <br />P <br />❑Appro ed Approved with conditions ❑Disapproved <br />L <br />(S 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 TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature Title Date <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 />Alexia Inigues <br />NAME Barghausen Consulting Engineers, Inc. TITLE Project Planner PHONE # (425) 251-6222 <br />ADDRESS 18215 - 72nd Avenue South, Kent, WA 98032 <br />SIGNATURE <br />M. Alexia Inigues <br />EH230038 (revised 12/31/07) <br />III <br />