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Environrr '!'t�QjFRVED <br /> SAN JOAQUIN <br /> COUNTY <br /> FEB 0 7 2020 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMITENVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: DFPARTMENT <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # CAL000317368 Project Contact & Telephone # Mike Eliason , 209-993-8793 <br /> A <br /> C Facility Name Valley Pacific Petroleum Hwy 99 Cardlock Phone # 209-993-8793 <br /> I <br /> L Address 3550 S Hwy 99 , Stockton CA 95215 <br /> TCross Street Carpenter Rd <br /> Y Owner/Operator Valley Pacific Petroleum Services Phone # 209-948-9412 <br /> C Contractor Name Johnson Petroleum Construction Phone # 530-878-6834 <br /> 0 <br /> N Contractor Address P . O . Box 7169 , Auburn , CA 95604 CA Lic # 692238 Class A HAZ <br /> T <br /> A Insurer State Compensation Insurance Fund Work Comp # 9040729 <br /> C <br /> T ICC Technician 's Name Scott Johnson Expiration Date 8/30/2020 <br /> R ICC Installer' s Name Scott Johnson <br /> Expiration Date 8/30/2020 <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 Dispenser for Unl 87 and Dyed Dsl <br /> A <br /> N <br /> K <br /> P ❑ Approved ZApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date L� J 2 020 <br /> 14\ V I / <br /> APPLICANT MUST PERFORM ALL WO N 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 W RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signa tuV tleCommercial Fueling Manager Date 2/6/2020 <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 Valley Pacific Petroleum TITLE PHONE # 209-948-9412 <br /> ADDRESS 152 Frank West Cirlce , Stockton CA 95206 <br /> SIGNATUREeoo� /C DATE 2/6/2020 <br /> 2of6 <br /> i <br />