Laserfiche WebLink
SANJOAQUIN Environmental Health Department <br /> -- C0UNOFY -- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> 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 ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # CAL000275158 Project Contact & Telephone # Mike Eliason , 209111,993-8793 <br /> A <br /> C Facility Name Valley Pacific Petroleum Lodi Plant & Cardlock Phone # 209-993-8793 <br /> I <br /> L Address 930 E Victor Road , Lodi CA 95240 <br /> 1 Cross Street N Cluff Ave <br /> T <br /> Y Owner/Operator Valley Pacific Petroleum Services Phone # 209111948-9412 <br /> C Contractor Name BKR Services <br /> o Phone # (209) 64g-8789 <br /> N <br /> r Contractor Address 15009 Volta Rd . Los Banos , CA 93635 CA Lic # 898768 Class A HAZ <br /> RInsurer <br /> A DeJong Insurance Work Comp # H87925210AEM <br /> c ' <br /> ICC Technicians Name Jason Chamblin <br /> T Expiration Date 03/18/2023 <br /> oICC Installer' s Name Jason Chamblin <br /> R Expiration Date 03/18/2023 <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc. ) y Installed <br /> T Dispensers for Unl 87 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se At <br /> A tachment With Conditions) <br /> N Plan Reviewers Name IL,, <br /> bk Date_ L 1 1jj 2,^kjZ <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 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 /> Applicant's Signatures --- - ---- �;ti Project Manager 10/14/2022 <br /> Date <br /> IIIIIIIIIIIIE <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 Project Manager PHONE # 2091111948-9412 <br /> ADDRESS 152 Frank West Cirlce , Stockton CA 95206 <br /> SIGNATURE -- - DATE 10/14/2022 <br /> 2 of 6 <br />