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SANild O A Q U IN Environmental Health Department <br /> --- C O U N T Y ---_. <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THjEAPPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT [] PIPING REPAIRJRETROFIT VJUDC REPAIR/RETROFIT []COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Janelle Dockham (661 ) 631 -3870 <br /> A <br /> C Facility Name PERSHING GAS 4 LESS Phone # <br /> I <br /> L Address 4445 N . PERSHING <br /> I Cross Street <br /> T <br /> Y Owner/Operator DALJIT SINGH DBA PERSHING GAS 4 LESS Phone # <br /> c Contractor Name CONFIDENCE UST SERVICES , INC. Phone # (661 ) 631 -3870 <br /> O <br /> N Contractor Address 16250 MEACHAM RD . CA Lic # Class <br /> T <br /> R <br /> A Insurer STATE FUND Work Comp # 1308371 -2018 <br /> C <br /> T ICC Technician 's Name FRANK LANDA Expiration Date 1 /25/2019 <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 112, etc.) Installed <br /> T UDC 1 /2 GASOLINE <br /> A UDC 3/4 GASOLINE & DIESEL <br /> N <br /> K UDC 5/6 GASOLINE <br /> I <br /> UDV 7/8 GASOLINE & DIESEL j <br /> i <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name �^^ I I Date <br /> I <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 PERFOR NCE 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 COMENSATION LAWS OF CALIFORNIA. " CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PEFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA,11 <br /> PERMIT CLERK 6/27/2019 <br /> Applicant's Signature\ 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 JANELLE DOCKHAM TITLE PERMIT CLERK PHONE # 661 -631 -3870 <br /> 50 MEACHAM ROAD. BAKERSFIELD, CA 93314 <br /> ADDRESS <br /> 6/27/2019 <br /> SIGNATURE DATE <br /> 2of6 <br />