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.9255517888 Line 1 40 a.m. 04-07-2010 6/12 <br />QNVIKUNN& I AL MAL 1 M Vt K I MtN I <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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT PIPING REPAIR/RETROFIT OUDC REPAIR/RETROFIT <br />F <br />EPA Site # CAL000225805 <br />Project Contact & Telephone # Liddy McKenzie (925.551.7555) <br />A <br />C <br />Facility Name ARCO 5450 <br />Phone # (209) 983-9140 <br />I <br />L <br />Address 1617 W FREMONT ST, STOCKTON, CA 95203 <br />TCross <br />Street <br />Y <br />Owner/Operator BP West Coast Products LLC <br />Phone # <br />o <br />Contractor Name Gettler-Ryan Inc <br />Phone# (925) 551-7555 <br />T <br />Contractor Address 6747 SIERRA CT, SUITE J, DUBLIN, CA94668 <br />GA Lie # 220783 Class ns,e,o,cev,ee„ao,wsHie <br />A <br />Insurer STATE COMPENSATION INS FUND <br />Work Comp# 238-0003058 <br />C <br />T <br />ICC Technician's Certification Number 5250453 -UT <br />Expiration Date 05/15/2011 <br />R <br />ICG Installer's Certification Number 5250453-U1 <br />Expiration Date 12/30/2010 <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />DApproved pproved with conditions ❑Disapproved <br />L <br />(See Attac ent With Conditions) <br />A <br />N <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 AGENT'S 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 IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />=ORMIT <br />OF CALIFORNIA." <br />AppficantsSignatureile AGENT FOR OWNER Date 04/07/2010 <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 Liddv McKenzie TITLE Proiect Manager PHONE # 925.551.7555 <br />ADDRESS 6747 SIERRA CT, SUITE J, DUBLIN, 94568 <br />SIGNATURE <br />EH230038 (revised 8/8/06) <br />1 <br />