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ENVIRONMENTAL HEALTH DEPARTEIVED SAN JOAQUIN COUNTY 600 East Main Street, Stockton, California 95202 FEB 2 5 2014 Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIRONMENTAL APPLICATION FOR UNDERGROUND STORAGE TANK HEALTH DEPARTMENT RETROFIT OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE F EPA Site # CAL000317393 Project Contact & Telephone # Mike Eliason, (209) 993-8793 � Facility Name Valley Pacific Petroleum Fresno Ave Cardlock Phone # (209) 993-8793 1 L Address 1524 Fresno Ave, Stockton CA 95206 TCross Street Charter Way Y Owner/Operator Valley Pacific Petroleum Services, Inc. Phone # (209) 948-9412 C Contractor Name Kern County Construction Phone # 0 N T Contractor Address PO Box 6096, Bakersfield CA CA Lic # 481053 Class A,B, HAZ R A Insurer State Compensation Insurance Fund p Work Com # p 661-0000005 T ICC Technician's Name Josh Simmons Expiration Date 9/20/13 R ICC Installer's Name Josh Simmons Expiration Date 11/11/2013 Tank system work area Tank Size Chemicals Stored Currently Date UST (i e. 87 piping sump, 91 leak detector. UDC 112, etc.) Installed UDC 1/2 Diesel T A UDC 3/4 Diesel N K Diesel Piping Diesel P ❑ Approved Approved with conditions ❑ Disapproved L ttachment With Conditions) N Plan Reviewers Name Date APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." / Applicant's SignatelFe� Tine Cardlock Manager Date BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. NAME Valley Pacific Petroleum TITLE PHONE # (209) 993-8793 AD SIGNA 166 Frank West Circle, Stockton CA 95206 EH230038 (revised 08/1/11)