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9255517888 Line 048 a.m, 07-21-2016 4117 <br /> 40 <br /> SAN JOAQUIN COUNTY JUL 2 1 26116 <br /> 600 East Main Street,Stockton,California 95202 h <br /> Telephone: (209)468-3420 Fax: (209)468-3433 - d� <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 1Z TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Liddy McKenzie (925.551,7555) <br /> A <br /> C Facility NameARCO 5450 Phone# 209.462.1617 <br /> Address 1617 W FREMONT <br /> T Cross Street N PERSHING AVENUE <br /> Y Owner/Operator BP West Coast Products LLC Phone# 530.621.0770 <br /> C Contractor NameGettler-Ryan Inc Phone# (925)551_7555 <br /> T Contractor Address 8805 SIERRA CT,SUITE G,DUBLIN,CA94568 CA Lac# 220793 ClaSSa,aas.WA41 aa004Hro <br /> A Insurer State Compensation Ins Fund work Comp# 9051229-3 <br /> T ICC Technician's Name TIM ADAMS Expiration Date 5/26/2017 <br /> Q <br /> R ICC installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> #,e,87 piping sump,91 leak detector,UDC U2,eu.I y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date L <br /> B <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 LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicenrs Sigrrat,,re ''"I r rue AGENT FOR OWNER Date7/05/2016 <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 /> NAMELiddy McKenzie TITLE Project Manager PHONE#925.551.7555 <br /> ADDRESs6805 SIERRA CCT SUITE G, DUBLIN, 94568 <br /> SIGNATURE 4-^C y- DATE �l-9� <br /> EH230038(revised 02/20/09) <br />