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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY RECEIVED <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (269) 468-3420 Fax: (209) 468-3433 MAR 13 2017 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br />THIS PERMIT EXPIRES 180 DAYS' FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW: DEPARTMENT❑ TANK RETROFIT N PIPING REPAIRIRETROFIT M UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # Prdject Contact & Telephone # <br />A <br />C <br />Facility Name Loves Travel Stop <br />Phone # (209) "599-0740 <br />i <br />L <br />Address 1 553 West Colony Road <br />I <br />T <br />Cross Street Jack Tone Road <br />Y <br />Owner/Operator <br />Phone # <br />e <br />Contractor Name L.A. Perks Petroleum Specialists; Inc. <br />Phone # (775) 358-4403 <br />0 <br />N <br />Contractor Address. 765 East Greg Street #103 Sparks, NV. 89437 <br />CA Uc # 678948 Class A, C; HAZ <br />f <br />R <br />A <br />Insurer MMT Insurance <br />Work Comp # 169928717 3 �t <br />T <br />ICC Technician's Name RobertAlfers <br />Expiration Date 1213/2018 <br />o <br />R <br />ICC Installer's Name Mike Koenig <br />Expiration Date 7/21118 <br />Tank system work area <br />-112, <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(Le. 87 piping sump; g1 leak detector. UM etc) <br />T <br />Diesel <br />20100.0 <br />Existing <br />A <br />Diesel <br />20,000 <br />Existing <br />N <br />K <br />Regular <br />20,0:00 <br />Existing <br />Regular Unleaded 1,P,remium Unleaded <br />12,00018;000 <br />Existing <br />❑ ❑ Disapproved <br />P <br />Approved "Approved with conditions <br />L <br />(gee Attachment With Conditions) <br />A <br />N <br />Pian Reviewers Name Date <br />APPLICANT MUST PERFORMALL WORK. INACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,: STATE LAWS, AND. RULES. AND REGULATIONS OF SAN <br />JOAQUIN, COUNTY,. ENVIRONMENTAL HEALTH DEPARTMENT." OWNER.OR LICENSED. AGENT'S SIGNATURE CERTIFIE$. 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 C. FORNIA." CONTRACTOR'S. HIRING OR SUBCONTRACTING SIGNATURE' CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE -PERFORMANCE OF T E _ RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.!' <br />Applicant's SignatureZ�e_Title Director Date MM&fff 3 1Ohi <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional ERD 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 L.A. Perks Petroleum Specialists 1 Keith Perks TITLE Director PHONE # 775-358-4403 <br />765E Greg <br />EH230038 (revised 101.39112) <br />2 <br />7 <br />