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ri <br /> SANJOAQUIN Environmental Health Department <br /> — COUNTY --- - .Jh. INI <br /> APPLICATION FOR UNDERGROUND STORAGE TA <br /> MV1140NMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <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 # CAL000289551 Project Contact & Telephone # Mike Eliason , 209-993-8793 <br /> A <br /> C Facility Name Valley Pacific Petroleum Cardlock-Charter Way Phone # 209 -993-8793 <br /> I <br /> L Address 1501 W Charter Way , Stockton CA 95206 <br /> 1 Cross Street Fresno Ave <br /> T <br /> Y Owner/Operator Valley pacific Petroleum Phone # 209 -948-9412 <br /> c Contractor Name CGRS Phone # 626 -627-8316 <br /> O <br /> N Contractor Address 5444 Dry Creek Rd , Sacramento , CA 95838 CA Lic # 803616 Class A HAZ <br /> T <br /> R <br /> A Insurer Zurich American Insurance CO Work Comp # WC 4632690-008 <br /> T <br /> r ICC Technician's Name Richard Thomas Expiration Date 11 /3/2020 <br /> R ICC Installer's Name Richard Thomas Expiration Date 11 /2/2020 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (0, 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> .t. B20 Fill Drop Tube 120000 B20 1987 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L l (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name t f I � ' Date <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 Signatute � Title Zu��{�'«< / �' � � Date Z.0 'Z0 <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 <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Mike Eliason TITLE Commercial Fueling Manager PHONE # 209-993-8793 <br /> ADDRESS 152 Frank West Circle, Stockton , CA 95206 ( "j� <br /> \Ol <br /> SIGNATUf�� DATE /zo /zy <br /> 2of6 <br />