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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 18D DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 8 TANK RETROFIT 10 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 Fastlane Gas Central Valle Phone# 209-234-4341 <br /> IAddress <br /> L 116 E Roth Rd. Lathrop CA 95330 <br /> I Cross Street Harlan <br /> T <br /> Y Owner/Operator Hardeep Gill Phone# 707-431-0541 <br /> Do Contractor Name Service Station Systems, Inc. Phone# 408-213-6038 <br /> NContractor Address ss 680 Quinn Avenue CA LIc# 485184 Classg C61/040 HAZ <br /> A Insurer ICW Group Work Comp# WPL502130700 <br /> DICC Technician's Name <br /> T Jeremy Findley Expiration Data 6/1/2013 <br /> R ICC Installers Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> pe.aT pintas amp.91 na delecr04 UDC I/I,W.) y Installed <br /> T <br /> A <br /> N <br /> K v <br /> P EJ Approved pproved with conditions L] Disapproved <br /> L (S Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <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: '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 /> ApWicenrsslgnewrel'( ��-ti � '��-L�� 'L+- -d-4�%Tme Compliance Officer Data 6/21/2012 <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 /> 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 IQ adal.LL% V "A-L�U DATE 6/21/2012 <br /> EH230038(revised 02/20109) <br /> 1 <br />