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9255517888 Line 40 1W a.m. 11-19-2009 4115 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />-— —.—.•--T.MtCrR.TZ.tP,TO_4r./IlSR. J1TRlI�,T.L/R49.0%^- ----— ----- <br />1Z TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # CAL000276251 <br />Project Contact & Telephone # Liddy McKenzie (925.551.7555) <br />A <br />C <br />Facility NameARCO 5450 <br />Phone # (209) 462-1617 <br />1 <br />L <br />Address 1617 W FREMONT ST, STOCKTON, CA 95203 <br />I <br />T <br />Cross street N Parishing Ave <br />Y <br />Owner/operator BP West Coast Products LLC <br />Phone # <br />C <br />Contractor Name Gettler-Rya n Inc <br />Phone # (925) 551-7555 <br />T <br />Contractor Address 6747 SIERRA CT, SUITE J, DUBLIN, CA94568 <br />CA Lic # 220793 Cla$s4 a,Cf0,C57,Cd1 n<D F�OC <br />A <br />Insurer STATE COMPENSATION INS FUND <br />work comp # 238-0003058 <br />° <br />7 <br />ICC Technician's Name 5250453 -UT <br />Expiration Date 05/15/2010 <br />°R <br />ICC Installer's Name 5250453 <br />-UI <br />Expiration Date 12/30/2009 <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ ApprovedApproved with conditions El Disapproved <br />L <br />(S Attachment With Conditions) / <br />N <br />Q7 <br />Plan Reviewers Name:2f 00 - <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 <br />TO WORKER'S COMPENSATION LAW CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF WO K OR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature Title AGENT FOR OWNER Date11/19/2009 <br />`� BILLING INFORMATION: <br />Indicate the responsi le 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 TITLE Project Manaqer PHONE #925.551.7555 <br />ADDRESSEE SIERRA CT, SUITE J, DUBLIN, 94568 <br />EH230038 (revised 02/20/09) <br />1 <br />