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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) 4683433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 100 DAYS FROM THE APPROVAL DATE: INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETRO FIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # MERLIN BOWEN 925, 551 .7555 <br /> C Facility Name ARCO SS# 608 Phone # <br /> I <br /> L Address 85 E LOUISE AVENUE <br /> TCross Street <br /> Y Owner/Operator BP WEST COAST PRODUCTS LLC Phone # 530 .771 -8942 <br /> c Contractor Name Gettler Ryan Inc. Phone # 925 , 551 .7555 <br /> 0 <br /> N Contractor Address 6805 Sierra Court, Suite G, SUITE G CA Lic # 220793 ClasSA/B/C61 -D4 /CII <br /> T <br /> R <br /> A InsurerZURICH AMER INS COMPANY Work Comp # WC090463403 <br /> T ICC Technician's Name MIKE O'SULLIVAN Expiration Date 5/26/2023 <br /> R ICC installer's Name MIKE O'SULLIVAN Expiration Date 12/29/2022 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, a7 plptnp sump, 91 leak deledar, UDC 112, etc,) Installed <br /> PREMIUM UNLEADED 20,000 87 GASOLINE <br /> A REGULAR UNLEADED 12,00V9PLITTANK 91 GASOLINE <br /> N <br /> K REGULAR UNLEADED 10,00MPLIT TANK DIESEL <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name f �� r Date J �' L L <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 151SSUED, I SHALL NOT EMPLOYANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECTTO <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." f <br /> pplUnl'sSignature / TIueAGENT FOR OWNER Date 41/13/2022 <br /> BILLING INFORMATION : I <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 /> ADDREss6805 SIERRA CT , SUITE G , DUBLIN , 94568 <br /> SIGNATURE i DATE 4II4I2022 <br /> Y. <br /> EH230038 (revised 07-17 ` 014) <br /> 2 <br />