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SAN10 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 /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT X UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Jesse 209 - 715 - 0124 <br /> G Facility Name Valero Hammer Lane Phone # 2 () 97150124 <br /> _ _ <br /> L Address 0 E . Hammer Lane , Stockton , California <br /> Cross Street West Lane <br /> T <br /> Y Owner/Operator First Evergreen Oil Corporation DBA Tiwana Gas Phone # 209 -715 - 0124 <br /> 0 <br /> Contractor Name Douglas Young , III DBA Confidence UST Services Phone # 661 -631 - 3870 <br /> T Contractor Add ress16250 Meacham Road Bakersfield CA CA Lic # 804904 Class A <br /> A Insurer StateCom ensation Insurance Fund CA Work Comp # 1308371 -21 <br /> T <br /> T ICC Technician 's Name Frank Landa Expiration Date 01 /28/2023 <br /> R ICC Installer's NameExpiration Date <br /> Frank Landa 01 /28/2023 <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 Regular Unleaded 12000 <br /> A Premium Unleaded 10000 <br /> N <br /> K Diesel 12000 <br /> P ❑ Approved LZApproved with conditions ❑ Disapproved <br /> L Adtachment With Conditions) <br /> A _ <br /> N Plan Reviewers Name Date � �/ � C �� � <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> OAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY THAT IN <br /> HE 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." 2 <br /> pplicant's Signature <br /> Dom`""" L Title Permit Clerk Date 05/05/2021 <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 it 661 -631 -3870 <br /> ADDRESS 16250 Meacham Road , Bakersfield , CA 93314 <br /> SIGNATURE P&O lla4lt� DATE 05/05/2021 <br /> 2 of 6 <br />