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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <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# <br /> A <br /> C Facility Name Valley Pacific Fresno Ave Cardlock Phone# 209 993-8793 <br /> I Address 1524 Fresno Ave, Stockton CA 95206 <br /> I Cross Street Charter Way <br /> T <br /> Y Owner/Operator Valley Pacific Petroleum Services, Inc. Phone# (209) 993-8793 <br /> C Contractor Name Kern County Construction Phone# (661) 203-3096 <br /> N <br /> r Contractor Address P.O. Box 6096, Bakersfield CA 93386 CA Lic# 481053 Class A <br /> A Insurer State Compensation Insurance Fund Work Comp# 044-0003848 <br /> TICC Technician's Name Josh Simmons <br /> T Expiration Date 9/16/11 <br /> R ICC Installer's Name Josh Simmons Expiration Date 9/16/11 <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 Spill Bucket 20K Diesel <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions Ii Disapproved <br /> L (See ment With Conditions) <br /> A <br /> N Plan Reviewers Name Date 257 // <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 <br /> TO 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 /> ,a <br /> Applicant's Signaturei e Cardlock Manager Date 3/24/2011 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> NAME Valley Pacific Petroleum TITLE PHONE# (209) 948-9412 <br /> ADDRESS 188 A Frank West Circle Stockton CA 95206 <br /> i <br /> SIGNATURE .' (s / DATE 3/24/2011 <br /> EH230038(revised 07/22/10) <br /> 2 <br />