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9- E(�EIVED <br /> S A N J O A Q U I N Environmental Health <br /> �D�p�r n �tg <br /> —COUNTY - 11 ! <br /> ENVIRONMENTAL <br /> APPLICATION FOR UNDERGROUND STORAGE TANKHEAJH nFIDARTMENT <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMITTYPE BELOW: <br /> ❑TANK RETROFIT X PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Mike Eliason, (209)993-8793 <br /> A <br /> C Facility Name Valley Pacific Petroleum Lodi Plant and Cardlock Phone# (209)993-8793 <br /> I <br /> L Address 930 E Victor Road, Lodi CA <br /> T Cross Street N Cluff Ave <br /> Y Owner/Operator Valley Pacific Petroleum Services Phone# (209)948-9412 <br /> o Contractor Name CGRS Phone# (626)627-8316 <br /> T Contractor Address 5444 Dry Creek Rd, Sacramento, CA 95838 CA Lic# 803616 Class A HAZ <br /> R Insurer <br /> A ,Zurich American Insurance Co Work Comp# WC 4632690-008 <br /> cICC Technician's Name <br /> T Richard Thomas Expiration Date 11/3/2020 <br /> ' <br /> ICC Installers Name Richard Thomas <br /> R Expiration Date 1112!2020 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i_e_87 plpinq sump.91 leak detector,UDC 112,etc.) Installed <br /> T Unl 87 Vapor and Fdl Bucket 9,aao Unleaded 87 <br /> A <br /> N <br /> K <br /> P U Approved Approved with conditions ❑ Disapproved <br /> L See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date��� t I l <br /> APPLICANT MUST PERFORM ALL WORK IN CCOROANCE WITH SAN JOAgUIN 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" //�� 1 y!' <br /> Applicants Signat Title 6 W(011 0$4601 ! orf 4 v Date 7 <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 Commercial Fueling Manager PHONE# (209)993-8793 <br /> ADDRESS 152 Frank West Circle,Stockton CA 95206 <br /> SIGNATIE -4 � DATE <br /> v <br /> 2 of 6 <br />