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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 /> 8 TANK RETROFIT ID PIPING REPAIRIRETROFIT 8 UDC REPAIRlRETROFIT 8 COLD START/EVR UPGRADE <br /> F EPA Site# Pro)ect Contact&Telephone#Marty Weithman 408-213-6038 <br /> A <br /> G Facility Name Fast Lane Central Valley Phone# 209-234-4341 <br /> IAddress <br /> L 116 E Roth Rd. Lathrop CA 95330 <br /> 1 Cross Street Harlan <br /> T <br /> Y Owner/Operator B&G Group Inc Phone# 707431-0541 <br /> G Contractor Name Service Station Systems, Inc. Phone# <br /> o Y 408-213-6038 <br /> N Contractor Address <br /> T 680 Quinn Avenue CA Lie# 485184 Classg C61/1)40 HAZ <br /> R Insurer <br /> A Cypress Insurance Company Work Comp# 3310020636091 <br /> cICC Technician's Name <br /> T Bryan Lundien Expiration Dale 10/23/2011 <br /> R ICC Installer's Name Expiration Date <br /> Tank system Work area Tank Size Chemicals Stored Current) Dale UST <br /> (i.e 87 pipin M.P.91"k d.Wtoi,UDC 1Q,W.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions Disapproved <br /> A <br /> L (See Attachment With Conditions) <br /> II /� <br /> N Plan Reviewers Name --2 Date Ll,. . br, <br /> � �1 <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 WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 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.' �v11 1ff�, <br /> Applkanrs Slgnot" f'L lAarti� J/U <br /> . V Compliance Officer D9m 12/6/2010 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per lank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Marty Weithman TITLE Compliance Officer PHONE# (408)213-6038 <br /> ADDRESS 680 Quinn Ave.San Jose,95112 <br /> SIGNATURE Y�,( CUCtLA � -i�-'�'C��LLl-�}-'K ) DATE <br /> "� 12/6/2010 <br /> EH230038(revised 0220109) <br /> 1 <br />