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SAN JOAQUIN Environmental Health De a <br /> COUNTY :: ; EDL <br /> APPLICATION FOR UNDERGROUND STORAGE TANK JAN 0 7 2019 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> EvvIRO�;nAENTAL <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: —Pb <br /> i l H r,)-PARWFNT <br /> ❑TANK RETROFIT X PIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/6-6b GRADE <br /> F EPA Site# 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 /> 1 Address 3550 S Hwy 99, Stockton CA <br /> TCross Street Carpenter Road <br /> Y Owner/Operator Valley Pacific Petroleum Services Phone# (209)948-9412 <br /> CContractor Name CGRS Phone# (626)627-8316 <br /> 0 <br /> T Contractor Address 5444 Dry Creek Rd, Sacramento,CA 95838 CA Lic# 803616 Class A HAZ <br /> R Insurer Zurich American Insurance Co Work Com # <br /> A P WC 4632690-008 <br /> C ICC Technician's Name Expiration Date <br /> T Richard Thomas P 11/3/2020 <br /> o ICC Installer's Name Richard Thomas <br /> R Expiration Date 11/2/2020 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leek detector,UDC 12,etc.) Installed <br /> T Dyed Diesel Fill Bucket 3,000 Dyed Diesel <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L e chment With Conditions) <br /> N Plan Reviewers Name Date J �r 3 2 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA`NWWITH 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 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 /> Applicants Signature Title Rfi/i&GG '►� Date <br /> 12 <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 <br /> SIGNATURE DATE b7h <br /> 2of6 <br />