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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY E 6�CrtIVEL <br />1868 E. Hazelton Ave., Stockton, California 95205 JUN 12 2015 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK UVIRCJNMEIVTAL <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT 0 PIPING REPAIR/RETROFIT M UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPASite# CAL000317393 <br />Project Contact & Telephone # Mike Eliason, (209) 993-8793 <br />A <br />0 <br />Valle Pacific Petroleum Charter Way Cardlock <br />Facility Name Y Y <br />Phone # ( 209)993-8793 <br />I <br />Address 1524 Fresno Ave, Stockton CA 95206 <br />L <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator Valley Pacific Petroleum Services <br />Phone# (209) 948-9412 <br />C <br />Contractor Name Kern County Construction <br />Phone# (661) 634-9950 <br />0 <br />N <br />Contractor Address PO Box 6096, Bakerfield Ca 93386 <br />CALic# 481053 Class A Haz <br />T <br />R9113736 <br />State Fund <br />Work Comp # 9113736 <br />A <br />0 <br />T <br />ICC Technician's Name Josh Simmons <br />Expiration Date 10/2015 <br />010/2015 <br />R <br />Installer's Name Josh Simmons <br />Expiration Date 10/2015 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector. UDC 112, etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />L <br />❑ Approved Approved with conditions ❑ Disapproved <br />tachment With Conditions) <br />A <br />9 <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORD E 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 />HE 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 LAW'S <br />OF CALIFORNIA." <br />Cardlock Manager ���(�/� <br />�' � �— Date <br />Applicant's Sign tur Title <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 Mike Eliason TITLE Cardlock Manager PHONE# (209) 993-8793 <br />166 Frank West Circle, Stockton CA 95206 <br />SIGNATURE <br />EH230038 (revised 07-17-2014) <br />TE G%((/�S— <br />