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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) 468 - 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 EPA Site # Project Contact & Telephone # MERLIN BOWEN 925 . 551 . 7555 <br /> C Facility Name ARCO SS# 5450 Phone # 209 . 462 . 1617 <br /> L <br /> Address 1617 W . FREMONT STREET <br /> I Cross Street N . PERSHING AVENUE <br /> T <br /> Y Owner/OperatorBP ARCO WEST COAST PRODUCTS LLC Phone # 530 . 470 . 6133 <br /> C Contractor Name Gettler Ryan Inc . Phone # 925 . 551 . 7555 <br /> O <br /> N Contractor Address 6805 Sierra Court , Suite G , SUITE G CA Lic # 220793 Class A/B/C61 - D40/CI <br /> T <br /> A Insurer State Compensation Ins Fund Work Comp # 9051229-3 <br /> C <br /> r ICC Technician 's Name TIM PERRY Expiration Date 3/22/2020 <br /> o <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 12 , 000 GASOLINE UNKNOWN <br /> A DROP TUBE 12 , 000 GASOLINE UNKNOWN <br /> N <br /> K DROP TUBE 123000 GASOLINE UNKNOWN <br /> P Approved ❑ Approved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions) <br /> A I <br /> N Plan Reviewers Nameati+ 1 I� S l� Date t l Y I19 <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 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 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 /> Applicant's Signature 'N Tide Date <br /> FOR OWNER U//09/2019 <br /> Date <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 /> NAME Liddy McKenzie TITLE Project Manager PHONE # 925 . 551 . 7555 <br /> ADDRESS 6805 SIERRA CT , SUITE G , DUBLIN , 94568 U <br /> SIGNATURE tIv/ A DATE � � y l <br /> EH230038 (revised 07- 17-2014) <br /> 2 <br />