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0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />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 ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # Merlin Bowen 925.551.7555 <br />A <br />C <br />Facility Name ARCO # 2093 <br />Phone #209.835-1605 <br />� <br />Address 345 Tracy Blvd., Tracy, CA. 95376 <br />TCross <br />Street Clover <br />Y <br />Owner/OperatorBP West Coast Products LLC <br />Phone# <br />o <br />Contractor Name Gettler Ryan Inc. <br />Phone #925.551.7555 <br />N <br />T <br />Contractor Address 6805 Sierra Court, Suite G, Dublin, CA. 94568 <br />CA Lic # 220793 Class Ai B> tiAZ, <br />A <br />InsurerState Fund <br />Work Comp #905122914 <br />C <br />T <br />ICC Technician's Name Chris San Nicolas <br />Expiration Date 12/05/2016 <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />Annular space <br />10,000 gallon <br />gasoline <br />A <br />N <br />K <br />P <br />L Approved Approved with conditions L Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />r' <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 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 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 />`---�- <br />Permit Tech 9/01 /2015 <br />Applicant's Signature rye 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 />NAME Merlin Bowen TITLE Permit Tech PHONE # 925.551-7555 <br />6805 Sierra Court, Suite G, Dublin, CA. 94568 <br />... _.......... . <br />SIGNATU <br />EH230038 (revised 10/30/12) <br />2 <br />9/01/2015 <br />