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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY - , <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> JUN 12 2015 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ;-- HONMENA <br /> n�-Rarrte�.. <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT 0 PIPING REPAIR/RETROFIT PgUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPASite# CAL000289551 Project Contact&Telephone# Mike Eliason, (209) 993-8793 <br /> A Valle Pacific Petroleum Charter Way Cardlock 209) 993-8793 <br /> Facility Name Y Y Phone# <br /> 1 Address 1501 W Charter Way, Stockton CA 95206 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Valley Pacific Petroleum Services Phone# (209) 948-9412 <br /> C Contractor Name Kern County Construction Phone# (661) 634-9950 <br /> O <br /> N Contractor Address PO Box 6096, Bakerfield Ca 93386 CA Lie# 481053 Class A Haz <br /> T <br /> A Insurer State Fund Work Comp# 9113736 <br /> C <br /> T ICC Technician's Name Josh Simmons Expiration Date 10/2015 <br /> R ICC Installer's Name Josh Simmons Expiration Date 10/2015 <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 <br /> A <br /> N <br /> K <br /> P ❑ Approved )X-Pproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A � 2/ 5 <br /> N 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 /> HE 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 /> pplicant'sSignatur Title Cardlock Manager Date <br /> BILLING INFORMATION: <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 Mike Eliason TITLE Cardlock Manager PHONE# (209) 993-8793 <br /> ADDRESS 166 Frank West_Circle, Stockton CA 95206 <br /> SIGNATURE DATE A <br /> EH230038(revised 07-17-2014) <br /> 2 <br />