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SANJ O A O U I N Environmental Health Department <br /> C0UN i� Y <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> 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 ❑ COLD START/EVR UPGRADE <br /> F EPA Site # CAL000317393 Project Contact & Telephone # Mike Eliason , 209-993-8793 <br /> A <br /> C Facility Name Valley Pacific Petroleum Fresno Ave Cardlock Phone # 209-993-8793 <br /> I Address 1524 Fresno Ave , Stockton CA 95206 <br /> L <br /> TCross Street Charter Way <br /> Y Owner/Operator Valley Pacific Petroleum Services Phone # 209-948 -9412 <br /> C Contractor Name BKR Services <br /> a Phone # (209 ) 649 8789 <br /> N Contractor Address 15009 volta Rd . Los Banos , CA 93635 CA Lic # 898768 Class A HAZ <br /> T <br /> AInsurer DeJong Insurance Work Comp # H87925210AEM <br /> cICC Technicians Name Jason Chamblin <br /> T ' Expiration Date 01 /1212025 <br /> oICC Installer's Name Jason Chamblin <br /> R Expiration Date 05/6/2023 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump , 91 leek detector, UDC 1124 etc.) Installed <br /> T Replace Diesel ( B20 ) Dispensers <br /> A <br /> N <br /> K <br /> P Approved pproved with conditions ❑ Disapproved <br /> L ( See At achment With Conditions ) <br /> A <br /> N Plan Reviewers Nam V7 r Date <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 WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA. " <br /> Applicant'sSignatur . � TmeProjectManager Date 10/ 14/2022 <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 Project Manager PHONE # 209-948 -9412 <br /> ADDRESS 152 Frank West Cirlce , Stockton CA 95206 <br /> SIGNATURE� DATE 10/ 14/2022 <br /> 2of6 <br />