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a � <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 MAR 2 5 2011 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENIRONMENTALHEALM <br /> RETROFIT OR PIPING REPAIR PERMIT PERMITISERVICES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> APhone# <br /> D Facility Name Valle Pacific H 99 Cardlock 209 993-8793 <br /> Address 3550 S Highway, Stockton CA 95206 <br /> I Cross Street Carpenter Ave <br /> Y Owner/operator Valley Pacific Petroleum Services, Inc. Phone# (209)993-8793 <br /> C contractor Name Tank Tek Environmental Corporation Phone# (707)446-6151 <br /> N Contractor Address 607 Elmira Road,Vacaville CA 95687 CA Lic# 803705 Class A <br /> T <br /> R <br /> Insurer Delos Insurance Company Work comp# 01DKRM22009625 <br /> GICC Technician's Name Mike Lawrence (1048103) Expiration Date 5/12/11 <br /> T <br /> R <br /> ICC Installer's Name Mike Lawrence Expiration Date 12/28/12 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak eetedor,UDC 112,etc.) Installed <br /> T Annualar Space Sensor Split 12K Unl 87/Dyed Diesel <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L e achment With Conditions) <br /> A — 1 <br /> N Plan Reviewers N e Date <br /> APPLICANT MUST PERFORM ALL WORK INA ANCE 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: "1 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 <br /> TO 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 /> Appllcanrs Signature _ y Cardlock Manager Date 3/24/2011 <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 acknowledge <br /> this responsibility for the billing by signature and date below. <br /> NAME Valley Pacific Petroleum TITLE PHONE# (209) 948-9412 <br /> ADDRESS 188 A Frank West Circle Stockton CA 95206 <br /> SIGNATURE 1j" --" DATE 3/24/2011 <br /> EH230038(revised 07/22/10) <br /> 2 <br />