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SAN-] A UIN <br />COUNTY <br />Environmental Health Department <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 X UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project contact & Telephone Wanelle Dockham (66 1) 631-3870 <br />� <br />Facility NamePershing Gas 4 Less <br />Phone # (209) 477-8004 <br />1 <br />Address 4445 N. Pershing Avenue, <br />Stockton, CA <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator Daljit Singh DBA Pershing Gas 4 Less <br />Phone# 209 477-8004 <br />o <br />contractor Name Nwestco LLC <br />Phone #(661) 631-3870 <br />"Contractor <br />Address 2209 Zeus Court <br />CA Lic # 1073967 Clap, HazC61 /D40 <br />T <br />A <br />InsurerOhio CasualtyInsurance Companywork <br />comp #XWS57384241 <br />TICC <br />Technician's Name Frank Landa <br />Expiration Date 01/20/23 <br />T <br />QICC <br />Installer's Name Frank Landa <br />Expiration Date 01/20/23 <br />R <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />e UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.)E <br />UDC 1/2 <br />GASOLINE <br />!Installed <br />A <br />UDC 3/4 <br />GASOLINE AND DIESEL <br />K <br />UDC 5/6 <br />GASOLINE <br />UDC 7/8 <br />GASOLINE AND DIESEL <br />P <br />❑ Approved <br />Approved with conditions ❑ Disapproved <br />L <br />(=h th Conditions) <br />A <br />" <br />3 I I <br />Plan Reviewers Name <br />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, <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT <br />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 <br />HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." gawie�&cle4 9� <br />D��` <br />Permit Clerk 11/09/2021 <br />Applicant's <br />Signature <br />Title Date <br />u <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 <br />Permit Clerk <br />ADDRESS 2209 Zeus Court Bakersfield CA 93308 <br />SIGNA <br />2of6 <br />ONE # 661-631-3870 <br />1• 1 <br />