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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : ( 209 ) 468 -3420 Fax : (209) 46 & 3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/ RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F pInsurerState <br /> e # Project Contact & Telephone # MERLIN BOWEN 925 . 551 . 7555 <br /> A <br /> C Name ARCO SS# 5450 Phone # 209 . 462 . 1617 <br /> I 1617 W . FREMONT STREET <br /> L <br /> T treet N . PERSHING AVENUE <br /> Y OperatorBP ARCO WEST COAST PRODUCTS LLC Phone # 530 . 470 . 6133 <br /> C tor Name Gettler Ryan Inc. Phone # 925 , 551 , 7555 <br /> N tor Address 6805 Sierra Court, Suite G , SUITE G CA Lic # 220793 ClassA/B/C61 - D40/CI <br /> T <br /> R <br /> State Compensation Ins Fund Work Comp # 9051229-3 <br /> T chnician 's Name TIM PERRY Expiration Date 3/22/2020 <br /> R ICC Installer's Name TIM PERRY Expiration Date 3/22/2020 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i .e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) Installed <br /> T DROP TUBE , BALL FLOAT CAGE 12 , 000 GASOLINE UNKNOWN <br /> A DROP TUBE , BALL FLOAT CAGE 129000 GASOLINE UNKNOWN <br /> N <br /> K DROP TUBE , BALL FLOAT CAGE 12 , 000 GASOLINE UNKNOWN <br /> GASOLINE <br /> P ❑ Approved pproved with conditions ElDisapproved <br /> L <br /> A (S chment With Conditions) <br /> G <br /> N Plan Reviewers Name w Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANC TH 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 CALI NIA." CONTRACTOR 'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WqJW FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER 'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title AGENT FOR OWNER Date 9/05/2018 <br /> BILLING INFORMATION : <br /> Indicate the responsible alt to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated ow 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 Manager PHONE # 925 . 551 . 7555 <br /> ADDRESS 6805 SIERRA CT , S G -ULIN , 94568 <br /> SIGNATURE DATE <br /> tZ 21 <br /> EH230038 (revised 07- 17-2014) <br /> 2 <br />