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SA N ?_ ( O A Q U I N Environmental Health Department <br /> -- COUNTY --- <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 /> 0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Ruben Byerley <br /> C Facility Name YRC # 813 Phone # 913-575-9563 <br /> I <br /> L Address 1535 E . Pescadero Avenue , Tracy, California 95304 <br /> TCross Street <br /> Y Owner/Operator YRC # 813 Phone # g13-575-9563 <br /> o Contractor Name Nwestco LLC Phone # 661 -631 -3870 <br /> T Contractor Address 2209 Zeus Court CA Lic # 1073967 cl az <br /> A Insurer Ohio CasualtV Work Comp # XWS57384241 <br /> T ICC Technician's Name Mike StromeCki Expiration Date 10/30/2022 <br /> QICC Installer's Name <br /> R Mike Stromecki Expiration Date 08/23/2022 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 81 leak detector, UDC 1/2, etc.) Installed <br /> T 4000 Diesel Waste <br /> N 1000 Waste Oil Water <br /> K 6000 Antifreeze <br /> 6000 Gear Oil <br /> 10000 Motor Oil <br /> 6000 Waste Oil <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A �,.. <br /> N Plan Reviewers Name Date I 01_ 15 ~ , lll <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "1 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's Signature 19et1L rue Permit Clerk Date 12/ 10/2021 <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 /> ADDRESS 2209 Zeus Court, Bakersfield , CA 93308 <br /> SIGNATURE DATE 12/ 10/2021 <br /> 2of6 <br />