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9255517888 Llne 1 016 p.m. 03-28-2016 4/10 <br /> SAN JOAQUIN C UNTY IVAIR 2 8 20 <br /> 600 East Main Street,Stockton,California 95202 a <br /> Telephone: (209)468-3420 Fax: (209)468-3433 " <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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8.Telephone# Liddy McKenzie (925.551.7555) <br /> A <br /> c Facility NameARCO 5450 Phone# <br /> I Address 1617 W FREMONT, STOCKTON <br /> TCross Street <br /> Y owner/operator gP West Coast Products LLC Phone# <br /> C Contractor NameGettler-Ryan Inc Phone# (925) 551-7555 <br /> T Contractor Address 6805 SIERRA CT,SUITE G,DUBLIN,CA94668 CA Lic# 220793 Classae,ct0ce,,ce1M40' zHro <br /> A insurer State Compensation Ins Fund work Comp# 9051229-3 <br /> T ICC Technician's Name BRIAN GAN Expiration Date 11/16/2016 <br /> R ICC Installer's Name BRIAN GAN Expiration Date 8/08/2016 <br /> Tank system work areaTank Size Chemicals Stored Currently Installed UST <br /> PA 87 piping swop,91 leak deflector,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved roved with conditions ❑ Disapproved <br /> L '' ee Attacbment With Conditions) <br /> A <br /> N 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CAUFOR A" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FgWMICH TtOS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Tltte AGENT FOR OWNER D..93/28/2016 <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 Proiect Manaqer PHONE#925.551.7555 <br /> ADDREss6805 SIERRA CTSUITE G IN 94568 <br /> SIGNATURE DATE <br /> EH230038(revised 02/201 <br /> 1 <br /> i <br />