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9255517899 Line 11 :08 a.m. 10-11-2010 3111 <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 186 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> C Facility NameARCO #2093 Phone# <br /> 1 Address 3425 TRACY BOULEVARD <br /> L <br /> I Cross Street <br /> Y Owner/Operator Phone# <br /> C Contractor NameGettler-Ryan Inc Phone# (925) 551-7555 <br /> T Contractor Address 6747 SIERRA CT, SUITE J, DUBLIN, CA94568 CA Lic# 220793 Cla4AZ,HIccn,c-suoao, <br /> R <br /> A Insurer Work Comp# D't�'UF�781'�F15{d <br /> T ICC Technician's Name OSS CARRASCO Expiration Date I 1120112-0 11 <br /> R ICC Installer's Name ;;T0%0 Expiration Date a1/28/ 012 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se ent With Conditions) <br /> INID4j <br /> Pian Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACC DANCE 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,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF ALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMAN=OF.THEKTHISPERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S C MPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants SignatureTitle Date <br /> /� 1 <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 L.,11�DY twACilKE1Z-I6 TITLE PHONE# 412-5. 55;1144 'X It <br /> ADDRESS W I L-V1 '5-11544t ``I•. 17T! J ClJC • el 4-540 eV <br /> SIGNATURE DATE l l <br /> EH230038(revisede?12Q 9) <br /> J 1 <br />