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0 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton,California 95202 <br /> Telephone: (209) 468-3420 Fax: (209)468.3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT 10 PIPING REPAIRlRETROFIT (I UDC REPAIRIRETROFIT 8 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> C Facility Name Fast Lane Gas Central Valle ) Phone# 209-234-4341 <br /> I Address <br /> L 116 E Roth Rd Lathrop CA 95330 <br /> T I Cross Street Harlan <br /> Y Owner/Operator Hardeep Gill Phone# 707-431-0541 <br /> D Contractor Name Able Maintenance, Inc. Phone# <br /> D 707-545-5522 <br /> T Contractor Address 3224 Regional Parkway, Santa Rosa 95403 CA l 312844 Claes g q C10 HAZ <br /> A Insurer Insurance Company of the West Work Comp# WPL500060302 <br /> T ICC Technician's Name Expiration Date <br /> 0 ICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Dale UST <br /> tie eT piping emap,e1 Wk detecw,uoc 1rz,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> ALN <br /> P Approved Approved with conditions Disapproved <br /> L (See Attachment tachment With Conditions) <br /> N Plan Reviewers Name 1,2 <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: '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 <br /> TO WORKERS COMPENSATION LAWS OF CALIFORNIA' CONTRACTORS 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 WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA' II +� <br /> Applicants Signature l.ir �/ V.,Z,Rr�A,l.l4lt.y . Compliance Officer Det. 7/28/2011 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responslbilky for the billing by signature and dale below. <br /> NAME Marty Weithman TITLE Compliance Officer PHONE# (408)213-6038 <br /> ADDRESS 680 Quinn Ave. Sant /Jose,95112�Q <br /> SIGNATURE � DATE 7/26/2011 <br /> EH230038(revised 02)20/09) <br /> 1 <br />