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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL H ALTH DEPARTMENT <br /> 304 E WEBERP VE,3RD FLOOR <br /> STOCKTO ,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 /> EPA SITE # ; PROJECT CONTACT & TELEPHONE # Scott Polston 925 551-7555 <br /> ------------------------------------------------------------------------------------------------------------------------------ <br /> F ; FACILITY NAME Fremont Arco ; PHONE # 9255 551-7555 <br /> C ; ADDRESS 1617 West -Fremont Street <br /> L ; CROSS STREET North Pershing Ave. <br /> I +----------------------------------------------------------------------- -------------------------------------' <br /> T OWNER/OPERATOR PHONE # - <br /> Y Fremont Arco (209)462-1617 <br /> C ; CONTRACTOR NAME Gettler Ryan Inc. ; PHONE #925 551-7555 <br /> N ; CONTRACTOR ADDRESS 6747 Sierra Court,Suite J Dublin I CA LIC # 220793 I CLASS a,b,c-10,haz,c57,c61,d40 <br /> ' T +----------------------------------------------------------------------------------------------------------------- <br /> R INSURER State Fund ; WORK.COMP.# 428-2004 <br /> A ______________________________________________________ _-_____________________+__________-_-_--_______-________________ <br /> C OTHER INFORMATION <br /> 0 PHONE # 925 551-7555 <br /> PHONE # <br /> +--;III ... ... .. . . . . .' ------------------------------- ---------------------------------------------------------- <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A6tt tt ��.. TACHMENT WITH CONDITIONS) <br /> ' N PLAN REVIEWERS NAME /'��2'ttWLLWA�W� (�/ 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 AMANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSA ION LAWS OF CALIFORNIA." CONTRACT S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE RFORMANCE F THE WORK FOR WH T PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF C FORNIA." <br /> APPLICANT'S SIGNATURE: TITLE Permit Expeditor DATE r/ �✓ ��I <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 SCOtt POI Ont A Dub" 94568 Phone # 925 551-7555 <br /> Signatur <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />