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,9255517888 Line 1 11• :42 a.m. 05-18-2009 4/12 <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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 10 TANK RETROFIT El PIPING REPAIRIRETROFIT 0 UDC REPAIR1RETROFIT El COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Liddy McKenzie (925.551.7555) <br /> A <br /> C Facility NameARCO 2093 Phone# <br /> I <br /> L Address 3425 TRACY BLVD, TRACY, CA 95376 <br /> 1 Cross Street CLOVER <br /> T <br /> Y Owner/operator BP West Coast Products LLC Phone# <br /> c Contractor NameGettler-Ryan Inc Phone# <br /> 0 (925)551-7555 <br /> N <br /> T Contractor Address 6747 SIERRA CT,SUITE J,DUBLIN,CA94568 CAUc# 220793 CIasSn,8,C1%C!Wr-61M40A4ZH1C <br /> R <br /> A insurer STATE COMPENSATION INS FUND work COITIP# 238-0003058 <br /> C ICC Technician's Name Expiration Date <br /> T 5250455-UT 06/12/09 <br /> 0 <br /> R ICC Installer's Name 5250455-Ul Expiration Date 06/28/09 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detedw,UDC 112,eft) Installed <br /> T <br /> A <br /> N <br /> K <br /> P 11 Appro Approved with conditions El Disapproved <br /> L e ee A chment With Conditions) A <br /> A IN Plan Reviewers Name Date <br /> 1 <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 AGENTS 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 <br /> TO WORKERS COMPENSATION LS OVA10FRORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF E RK WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicartrs Signature Titi. AGENT FOR OWNER oate5/18/2009 <br /> BILLING INFORMATION: <br /> Indicate the responsible partyo be billed 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 Liddv McKenzie TITLE Project Manaqer PHONE#925.551.7555 <br /> ADDRESs6747 SIERRA CT, SUITE J. DUBLIN, 94568 <br /> SIGNATURE DATE <br /> EH230038(revised 02/20/09) <br />