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9255517888 Line 110 53 a.m. 12-31-2009 4114 <br /> tNVIRONMATAL HEALTH UEI�►RTMENT <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. IMCATE PERMIT TYPE BELOW: <br /> �+J TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEWR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Liddv McKenzie (925.551.7555) <br /> A <br /> Facility NameARCO 2093 Phone# <br /> I <br /> L Address 3425 TRACY BLVD, TRACY, CA 95376 <br /> ' <br /> 1 Cross Street CLOVER <br /> T <br /> Y Owner/Operator BP West Coast Products LLC Phone# <br /> o Contractor NameGettler-Ryan Inc Phone# (925) 551-7555 <br /> N Contractor Address 6747 SIERRA CT,SUITE J,DUBLIN,CA94568 CA Lic# 2`20793 Classn.s.c,u.cay.c-c,roao,mA-,mc <br /> 7 <br /> A Insurer STATE COMPENSATION INS FUND Work Comp# 238-0003058 <br /> T <br /> T ICC Technician's Name 5250453-UT Expiration Date 05/15/2011 <br /> ° ICC Installer's Name 5250453-U[ Expiration Date 12/30/2010 <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Appr ved Approved with conditions ❑ Disapproved <br /> L ( achment With Conditions) <br /> A <br /> 1-0 <br /> N 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 WHIC IS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OFC ORNiA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE FO HICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title AGENT FOR OWNER Date12/31/09 <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 Liddy McKenzie TITLE Project Manaqer PHONE 4925.551.7555 <br /> ADDREss6747 SIERRA CT SUITE J DUBLIN, 94568 <br /> SIGNATURE DATE <br /> EH230038(revised 02/20/09) <br /> '7 <br />