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C <br />. • 111 11111110 1111 111 , . . <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />•• rr �- r - • <br />MA' I IM r: <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT SCOLD START/EVR UPGRADE <br />F <br />EPA Site # CAL000289551 <br />Project Contact & Telephone # Mike Eliason (209) 993-8793 <br />A <br />C <br />Facility Name Valle Pacific Petroleum - Charter a Cardlock <br />Phone # 209 993-8793 <br />I <br />L <br />Address 1501 W. Charter Way, Stockton, CA 95206 <br />TCross <br />Street <br />Y <br />Owner/Operator Valley Pacific Petroleum Services Phone # (209) 948-9412 <br />o <br />Contractor Name Elite IV Contractors Phone # (209) 942-4634 <br />T <br />Contractor Address 2535 Wigwam Dr 95205 <br />CA Lic # 660076 Class ACD+ Haz <br />A <br />Insurer Assurance <br />Work Comp # C03094176000 <br />C <br />T <br />ICC Technician's Name Fred Babel <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area Tank Size <br />Chemicals Stored Currently Date UST <br />(i.e. 87 piping sump, 91 leak detedor, UDC 1/2, etc.) <br />Installed <br />T <br />Veeder Root TLS - 350 <br />A <br />N <br />K <br />P <br />El Approved pproved with conditions El Disapproved <br />L <br />chment With Conditions) <br />A <br />N <br />% <br />Plan Reviewers Name Date �'2/ !/ d <br />4 4Z <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 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 />Applicant's Signature Title Date <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 />EH230038 (revised 07/22/10) <br />K <br />,TE 12/29/2010 <br />