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RECEIVED <br /> SANJOAQUIN Environmental Health Department <br /> -- - COUNTY - AUG 146 2022 <br /> APPLICATION FOR UNDERGROUND STORAGE TRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT 0 PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Jesse 209- 715 -0124 <br /> A <br /> C Facility Name Tiwana Gas & Food Phone # 209 - 715 -0124 <br /> � Address 1210 E . Hammer Lane Stockton California <br /> I Cross Street West Lane <br /> T <br /> Y Owner/operator First Evergreen Oil Corp , DBA Tiwana Gas & Food Phone # 209 - 715 -0124 <br /> o Contractor Name NWESTCO LLC Phone # 661 -631 -3870 <br /> T Contractor Address 2209 Zeus Court , Bakersfield , CA 9330 CA Lic # 1073967 class A Haz <br /> A Insurer Ohio Casualty Work comp # XWS57384241 <br /> T ICC Technician 's Name p 03/ 18/2023 <br /> T Terrence Lay Expiration Date <br /> oICC Installer's Name <br /> R Terrence Lay IExpiration Date 03 / 18/2023 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 1/2, etc, ) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions El Disapproved <br /> L ( e Attachment With Conditions) <br /> A //�� 7 <br /> N Plan Reviewers Name Date / 12j ZeZ - ( <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 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 �� Title Permit Clerk Date 08/ 16/2022 <br /> 61 <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 T�BC/� DATE 08/ 18/2023 <br /> 2of6 <br />