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19255517888 Main Fax GETTLER RYAN INC :41 p.m. 04-19-2007 4/12 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> 304 E WEBER AVE,3RD FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT_PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> — <br /> +---- --------------------------------------------------------- -------------------------------------------------------------+ <br /> EPA SITE #CAR000124420 1 PROJECT CONTACT 6 TELEPHONE # UDDY MCKEPOE 925 551.7555 <br /> ----....__----------------------------------------------------------------------------------------------- ------ <br /> F 1 FACILITY NAME CHEVRON 209167 I PHONE # 925 551-7555 <br /> ' A +------------------------------------------------------------------------------------------------------------------------------; <br /> C ; ADDRESS 1234 E YOSEMITE AVE <br /> I +----------------------------------------- -.... ..___..----- ------------------------------; <br /> L CROSS STREET <br /> I -------------------------- ---------—-------------------------------- ---------------------------------- —' <br /> T ; OWNER/OPERATOR ; PHONE 4 <br /> YCHEVRON <br /> , <br /> ---+----------------------------------------------------—__--------------------------- ------------------------------------ <br /> C I CONTRACTOR NAME Gettler Ryan Inc. PHONE #925 551-7555 ; <br /> ' 0 +---------------------------------------- ----------------------------; <br /> N ; CONTRACTOR ADDRESS 6747 Sierra Court,Suite Dublin CA LIC # 220793 CLASS a,b,c-10,hat,c57,c61,d40 <br /> ------------------------------ ---------; <br /> R INSURER State Camp Fund WORK.COMP.4_428-2007 <br /> A ----------------------------—--------------------+------------- -------------------------- <br /> I C ; OTHER INFORMATION <br /> 0 PHONE # 925 551-7555 <br /> R ---------------------------------------___.- -------------------------- ------------------------------------- <br /> ' PHONE. # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK ' ' <br /> ID # TANK SIZE ; CHF,MICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39-_ <br /> A 39- <br /> N 39- <br /> 1 K 39- <br /> 39- <br /> 1 <br /> 9-39-' 39 <br /> , <br /> +-L I ' II " I111' I �APPROVED1111 ' APPROVED WITH CONDITION(S) DISAPPROVED <br /> A INA <br /> �,1. (S E,ATTAC EWITH CONDITIONS) <br /> N PLAN REVIEWERS NAME '`/'\ NT DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS T'O <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANC OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> Agent for Owner 4/16/2007 ; <br /> APPLICANT'S SIGNATURE: TITLE g DATE , <br /> , <br /> +---------------------------------------- ------------------------------+ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> 6747 Sierra Court,Suite J <br /> Name LIDDY MCKENZIE Add SS Dublin 94566 -Phone# 925 551-7555 <br /> Signature ,f <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />