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19255517888 Main Fax <br />GETTLER RYAN INC <br />11 <br />01:07.45 p.m. 10-23-2006 2/6 <br />SAN JOAUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3- FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />ANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+---------------------------------------------------------------------------------------------------------------------------------+ <br />EPA SITE # ; PROJECT CONTACT & TELEPHONE # So" Poiston 525 551-7555 <br />F ; FACILITY NAME ARCO I ; PHONE # 925 551.7555 <br />' A +----------------------------------------------------------------------------'------------------ <br />C ; ADDRESS 2450 Jo• POmbo Parkway <br />' I +--------------------------------------------------------------------------- <br />L ; CROSS STREET Graotline <br />I+------------------------------------------------------------------------`-_ ' <br />T ; OWNER/OPERATOR ; PHONE # <br />Y ARCO <br />--------------------------------------------------------------------------------------------------------------------------------- <br />C CONTRACTOR NAME Getaer Ryan Inc.--------------------- ; PHONE # 925 551.7555 <br />o+--------------- - ------------------------------' <br />CA LIC # - -----------CLASS a,b,c-10,haz,c57,c61,d40 <br />N CONTRACTOR ADDRESS 9--- Sierra---- Court, Suite J Dublin 220793 <br />R ; INSURER State Fund ; WORK.COMP.# 426-2004 <br />, <br />A'-----------------------------------------------------------------------------`----------------------------- <br />C ; OTHER INFORMATION <br />, <br />T+------------------------------------------------------------------------------------+---------------------------- <br />0 ; ; PHONE # 925 551-7555 <br />R+----------------------------------------------------------------------� ------------+---`---------------------------------- <br />PHONE # <br />---------------------------------------------------------------------------------------------- <br />TANK�ID�#, i TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE VST INSTALLED <br />39- <br />3 39- <br />A 39- ' <br />N 39- <br />K 39- <br />39- <br />39- <br />, <br />+-L ,IItIII,,, " 1 „ 'I " APPROVEDAPPROVED WITH rCONDITION(S)_j DISAPPROVED;111III <br />A (SEE ATTACHMENT WITH CONDITIONS) meg <br />N PLAN REVIEWERS NAME— <br />DATE <br />DATE f <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: °I CERTIFY THAT IN THE PERFORMANqt OF WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." Y 7 <br />, APPLICANT'S SIGNATURE: TITLE Permit Expeditor DATE U 2LJO <br />+------------------------------------ ---- ------------------------------------------------------------------------------------- <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br />coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />6747 Sierra Court, Suite J <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />Dublin <br />1 <br />.ice <br /># 925 551-7555 <br />