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• <br />ENVIRONMENTAL HEALTH DEPARTMIY Zoog <br />SAN JOAQUIN COUNTY ENQER IT(s-RVICES HEALTHLIN IVIENT <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK 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 X COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name Valero 1 (15c-246) <br />lPhone# Zl" - -{7%-3111 <br />I <br />Address 1210 E. 142mrner L -ane, , S+oGk-ton <br />I <br />T <br />Cross Street k,2}61,rzri p.ive- <br />Y <br />Owner/Operator \/alero 9mr (prr- <br />Phone # j5q • 583.32�1g <br />C <br />Contractor Name },a r'etC&IeU n ServiC,-S, InG • <br />Phone # %Q]- 1p7g • $Il j <br />N <br />T <br />Contractor Address T5iO7 Rio Dixon I;o.2Ci Dikon <br />CA <br />A , Flzz GID <br />74Z4&�o Class t <br />RInsurer <br />A <br />D&2lps I r15urar►cL (fomp2my <br />Work Comp # <br />C <br />T <br />ICC Technician's Name utcholas Andraw� <br />Expiration Date 4 II /ocj <br />p' / <br />Q <br />R <br />ICC Installer's Name Ni�hvla �r'dru�rs <br />Expiration Date <br />P' <br />Tank system work area <br />(i.e. 87 piping sung, 91 leak detector, UDC 12, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />i <br />12 ,oma <br />Unk-24ed <br />N <br />#Z <br />IO Doo <br />Unlc�d <br />K <br /># <br />(),LY�O <br />Uri 2deA <br />P <br />❑ Approved _—SL6pproved with conditions <br />❑ Disapproved <br />L <br />A <br />(S ttachment With Conditions) <br />N <br />Plan Reviewers Name Date <br />V <br />APPLICANT <br />MUST PERFORM A&GK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN <br />COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE <br />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 <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />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 />r y <br />Applicant's Signature 2I -F 49 6 1>�''j(,r. Title Prof l la r • <br />Date zJ �l��Oq <br />"t't' BILLING INFOKMATION: <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 />4-- NAME <br />NAME ;&i42 6oninc (4f cbr%ke-) TITLE FfDj &4 M=iCr PHONE# 767-745-1640 ad- IX <br />ADDRESS _ II33 11• NG1�f7LxII 81V�1 ., PCfaluw►2 G,4 mit ��tm AianinD6 Starr.�,oll►� <br />V <br />DATE 3fia/oq <br />EH230038 <br />1 <br />