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9255517888 Line 0 010p.m. 01-26-2009 4/8 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,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 80 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 5 TANK RETROFIT LIPIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT <br /> F EPA Site# Project Contact&Telephone# Liddv McKenzie (925.551.7555) <br /> A Facility Name ARCO 2093 Phone# (209) 835.1605 <br /> Address 3425 N. Tracv Blvd., Tracy. CA. 95376 <br /> I Cross Street Clover <br /> T <br /> Y Owner/Operator BP West Coast Products LLC Phone# (209) 835.1605 <br /> C contractor Name Gettler-Rvan Inc Phone* (925) 551-7555 <br /> T Contractor Address 6747 SIERRA CT,SUITE J,DUBLIN,CA9456B CA Lic# 220793 Class Ae,CiD,Gar,CauMn,wcx,nc <br /> RInsurer STATE COMPENSATION INS FUND Work Comp# 238-0003058 <br /> A <br /> T ICC Technician's Certification Number 5259492-UT Expiration Date 05/18/2009 <br /> R ICG Installer's Certificatlon Number Canidate 1D XX4141014520 Expiration Date 12/20/2009 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P E]Approv d proved with conditions Disapproved <br /> L ( At"chment With Conditions) <br /> A <br /> N Plan Reviewers Name Date V <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: -1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHWH THIS PERMIT 15 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS FCA NIA," CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF E W EORYVHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> AppllcantsSignature l T1tls AGENT FOR OWNER Date 1/23/2009 <br /> BILLING INFORMATION: <br /> Indicate the responsible pIrtyo 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 Proiect Manaqer PHONE# 925.551.7555 <br /> ADDRESS 6747 SIERR CT U1TE J DUBLIN 94568 <br /> SIGNATURE <br /> EH230038(revised e181 ) <br /> 1 <br />