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SAN O A Q U I N Environmental,.M�etthemen <br /> VED <br /> -- COUNTY ---- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK FAL 1 2021 <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEAL7I- H <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOvV, FRMIT/ SFI \11CFS <br /> ❑ TANK RETROFIT N PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> rF EPA Site # CAL000317368 Project Contact & Telephone # Nic Poblano , (209) 639=2191 <br /> Phone # (209) 993-8793 <br /> Facility Name Valley Pacific Petroleum Hwy 99 Cardlock <br /> Address 3550 S Hwy 99 , Stockton , CA <br /> Cross Street Carpenter Rd <br /> T Phone # (209) 948-9412 <br /> Y Owner/Operator Valley Pacific Petroleum Services <br /> C Phone # (626) 627-8316 <br /> Q Contractor Name Kern County Constuction <br /> N Contractor Address P. O . Box 6096 , Bakersfield , CA 93386 CA Lic # 481053 Class A/B HAZ <br /> T Work Comp # 9113736 <br /> R Insurer State Compensation Insurance Fund <br /> A Expiration Date 1 /1512023 <br /> C ICC Technician' s Name Josh Simmons <br /> T 1 /15/2023 <br /> D Josh Simmons Expiration Date <br /> R ICC Installer' s Name <br /> Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br /> T <br /> UM 87 Fill Bucket 91000 Unleaded 87 <br /> A <br /> N <br /> K <br /> ❑ Approved ❑ Approved with conditions El Disapproved <br /> P (See Attachment With Conditions) <br /> A <br /> C�. ZULU <br /> Plan Reviewers Name <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 ORK R WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA:' JJ / s Z <br /> Applicant's Sign e <br /> /�� Title C G Ir V r Date �/ <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. 209 993-8793 <br /> Mike Eliason TITLE Commercial Fueling Manager PHONE # t <br /> NAME <br /> ADDRESS 152 Frank West Circle , Stockton CA 95206 <br /> DATE <br /> SIGNATURE�I?G <br /> 2of6 <br />