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5517888 <br />Llne 1 10:55:01 09-09-2013 <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 REPAIRiRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone #Liddy McKenzie 925.551.7555 <br />c <br />Facility NameARCO # 5450 <br />Phone #209.462.1617 <br />1 <br />L <br />Address 1617 W. Fremont Street <br />Cross Street 1-5 <br />Y <br />Owner/OperatorBl? West Coast Products LLC <br />Phone# <br />p <br />Contractor Name Gettler Ryan Inc. <br />Rhone #925.551.7555 <br />N <br />T <br />Contractor Address 6747 Sierra Court, Suite J <br />CA Lic # 220793 Claws: cs1 1) /0 and HAz <br />R <br />A <br />Insurer State Fund <br />Work Comp #238-0003058 <br />c <br />T <br />ICC Technician's Name Chris Reeves <br />Expiration Date <br />D <br />R <br />ICC lnstal]Ws Name Chris Reeves <br />Expiration Date <br />Tank system work area <br />(to. 87piping sump, 91 took dolodor, UDC 11,2, etc) <br />Tank Size Chemicals Stored Currently <br />y <br />Date UST <br />Installed <br />T <br />Al IC U 41ar4i;Va— <br />NIA gasoline <br />N/A <br />N <br />y3v--3y�/ <br />K <br />P <br />❑ Approved <br />Approved with conditions El Disapproved <br />L <br />A <br />N <br />( <br />Pian Reviewers Name��/ <br />chment With Conditions) <br />Date //3 <br />_ <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: 9 CERTIFY <br />THAT IN THE PERFORMANCE OF RK R WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OFCALIFORNIA" <br />AppiieaM's Slpnatum Tie r Data r 11,X./2013 <br />tl 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 TrTLE9/C4/2013 _ PHONE # 925.551.7555 <br />ADORFss 6747 Sierra CoylA, Sum Dublin, CA. 94568 <br />EH230038 (revised 10130112) <br />2 <br />6/' '2013 <br />3112 <br />