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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 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 N UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # CAL000289551 <br />Project Contact & Telephone # Mike Eliason (209) 993-8793 <br />Facility Name Valley Pacific Petroleum Charter Way Cardlock <br />Phone # (209) 993-8793 <br />� <br />Address 1501 W Charter Way, Stockton, CA 95206 <br />1 <br />T <br />Cross Street Fresno Ave <br />Y <br />owner/operator Valley Pacific Petroleum <br />Phone # (209) 993-8793 <br />C <br />O <br />Contractor Name Elite IV Contractors <br />Phone # <br />T <br />Contractor Address 2535 Wigwam, Stockton, 95205 <br />CA Lic # <br />660076 Class A B, C-10 H <br />A <br />Insurer ICW <br />Work Comp # 5003108 <br />T <br />T <br />ICC Technician's Name Joe Bartholdi (8012444 -UT) <br />Expiration Date 6/23/2010 <br />R <br />ICC Installer's Name Joe Bartholdi 8017009 <br />-UI <br />Expiration Date 4/9/2011 <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 />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />A <br />Se Attachment With Conditions) <br />N <br />Plan Reviewers Name 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 <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 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 />Cardlock Manager <br />Applicant's Signature Title ger Date 3/12/2010 <br />IQ I 14 1 41 Lei 104 M*1 V IT, MAI ILei I <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 TITLE PHONE <br />ADDRESS <br />EH230038 (revised 02120109) <br />1 <br />,TE <br />190 <br />