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SAN -JOAQUIN Environmental Health Department <br /> COUNTY---- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM TPPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT L✓�IUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#FRANK LANDA <br /> A <br /> C Facility Name ANGEL PETROLEUM Phone# <br /> I Address 7700 MORELAND STREET <br /> L <br /> I Cross Street E.HAMMER LANE <br /> T <br /> Y Owner/OperatorBALAJI ANGLE Phone#510-552-4822 <br /> C Contractor Name CONFIDENCE UST SERVICES,INC. Phone#(800)339-9930 <br /> 0 <br /> N Contractor Address 16250 MEACHAM ROAD <br /> T CA Lic# Class <br /> R <br /> A Insurer STATE FUND Work Comp#1308371-2017 <br /> 0 <br /> r ICC Technician's Name FRANK LANDA Expiration Date 1/25/2019 <br /> 0 <br /> R ICC Installer's Name FRANK LANDA Expiration Date 2/03/2020 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T UDC#5/6 GASOLINE/DIESEL <br /> A <br /> N <br /> K <br /> P ❑ Approvedpproved with conditions ElDisapproved <br /> L (See�chment With Conditions) <br /> A -� <br /> N Plan Reviewers NameXA � �� J"� 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 ORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSAT 1 WS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORM NCE THE ORK FOR IS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signatu Title 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. <br /> NAME ERIC SANTOS TITLE OFFICE CLERK PHONE#(323)485-1015 <br /> 16250 MEACHAM ROAD BAKERSFIELD,CA 93314 <br /> ADDRESS <br /> 5/15/18 <br /> SIGNATURE DATE <br /> 2 of 6 <br />