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SAN JOAQUIN Environmental Health Department <br /> - <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 /> TANK RETROFIT [] PIPING REPAIR/RETROFIT EUDC REPAIR/RETROFIT QCOLD START/ EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Jesse <br /> A <br /> C Facility Name Valero Hammer Lane Phone # (209) 715-0124 <br /> 1 Address 1210 E . Hammer Lane , Stockton , CA 95210 <br /> L <br /> TCross Street Tam O Shanter Drive <br /> Y Owner/OperatorValero Hammer Lane Phone # (209) 715-0124 <br /> C Contractor Name Confidence UST Services Phone # (661 ) 631 -3870 <br /> O <br /> T Contractor Address 2209 Zeus Court, Bakersfield , CA 93308 CA Lic #804904 Work Com # <br /> R Class A p <br /> A Insurer State Fund 1308371 -2021 <br /> C <br /> T ICC Technician' s Name Frank Landa Expiration Date 01 /28/2023 <br /> O <br /> R ICC Installer' s Name Frank Landa Expiration Date 01 /28/2023 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> > Installed <br /> T <br /> A <br /> N <br /> K <br /> P O Approved O Approved with conditions O Disapproved <br /> L Attachment With Conditions) <br /> N Plan Reviewers Name Date IO `�l / <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORD 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 THE <br /> 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 THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF <br /> CALIFORNIA. " <br /> D;)9 � Permit Clerk 09/14/2021 <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 acknowledge <br /> this responsibility for the billing by signature and date below. <br /> Janelle Dockham Permit Clerk 661 -631 -3870 <br /> NAME TITLE PHONE # <br /> ADDRESS 2209 Zeus Court Bakersfield CA 93308 <br /> 09/ 14/2021 <br /> SIGNATURE DATE <br /> 2 of 6 <br />