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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 /> ® TANK RETROFIT E PIPING REPAIRIRETROFIT 8 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 Central Valley Phone# 209-234-4341 <br /> I Address <br /> L 116 E Roth Rd. Lathrop CA 95330 <br /> I Cross Street Harlan <br /> T <br /> Y Owner/Operator g&G Group Inc Phone# 707-431-0541 <br /> c Contractor Name Service Station Systems, Inc. Phone# 408-213-6038 <br /> T Contractor Address 680 Quinn Avenue CA Lic# 485184 Classg C61/D40 HAZ <br /> AInsurer Cypress Insurance Company Work Comp# 3310020636091 <br /> T ICC Technician's Name Bryan Lundien Expiration Date 10/23/2011 <br /> RICC Installers Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Dale UST <br /> p.a.87 olpmo s�,s1 I k del lw,UDC 12.ft.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ® Approved Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers NameDate q <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: '1 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' 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 /> Appllcanrnsgnar. Yl• LCLu �� Compliance Officer Dal 11/2/10 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff lime 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 /> 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,,t9�5112 ! � - <br /> SIGNATURE I1 a.r-ru.L, V DATE 11/2/2010 <br /> EH230038(revised 02/21108) <br /> 1 <br />