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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 /> 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 OPIPWG REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # CAL000317393 P <br /> A roject Contact & Telephone # Mike Eliason <br /> C FacllltyName Valley Pacific Petroleum Fresno Ave Cardlock Phone # 209 - 993 - 8793 <br /> I <br /> L Address 1524 Fresno Aver Stockton CA 95206 <br /> TCross Street <br /> Y Owner/Operator Valley Pacific Petroleum Services , Inc . Phone # 209 - 948 - 9412 <br /> oContractor Name BKg Phone # <br /> T Contractor Address 15009 Volta Rd , Los Banos CA Lic # 898768 Class A <br /> A Insurer Acord Work Comp # H87925210AEM <br /> oechnicians Name Jason Chamblin <br /> T ICC Technician's Expiration pate 8/8/2025 <br /> R ICC Installer's Name lg <br /> Expiration Date <br /> Tank system workarea Tank Size ChemicalStd Current) Date UST <br /> (i.e. 87 piping sump, 91 leak detector, J0 1ns ore <br /> , etc,) y Installed <br /> T Piping from B20 Turbine sump to 20 , 000 Gallon Biodiesel, B20 5 /21 / 1997 <br /> A Dispenser 3 / 4 including Satellite 3 . <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N <br /> Plan Reviewers Na e " 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 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 WOR RIWHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA, " <br /> Applicant's Signatucc+'� tie Im . Cardlock Projects Manager Date 2/12/2024 <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 Valley Pacific Petroleum TITLE PHONE # 209 - 948 - 9412 <br /> ADDRESS 152 Frank Wes,> Circl <br /> SIGNATURE DATE__. <br /> EH230038 (revised 12"11A5) 2 <br />