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D OR IGINA I ENVIRONMENTAL HEALTH DEPARTM4ECEIVEL-) SAN JOAQUIN COUNTY 600 East Main Street, Stockton, California 95202 Telephone: (209) 468-3420 Fax: (209) 468-3433 FEB 0 3 2015 ENVIRONMENTAL APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REWA-q9PrMT" lC"1T THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE F EPA Site # Project Contact & Telephone # A C Facility Name FAST LANE - Lathrop Phone # 209 234-4341 1 L Address 116 E Roth Rd Lathrop 95330 I T Cross Street Y Owner/Operator B & G Group, Inc. Phone # 209 234-4341 C 0 Contractor Name Service Station Testing SST INC 9- Phone # 209 465-5577 ( ) N T Contractor Address PO Box 31465 - Stockton, CA 95213 CA Lic # 962520 Class q /e 1 C 0,20,36 A Insurer EXEMPT Work Comp # N/A T ICC Technician's Name Carl Wayne Henderson (5252923) Expiration Date 08/09/2016 o R ICC Installer's Name N/A Expiration Date p N/A Tank system work area Tank Size Chemicals Stored Currently Date UST Installed (i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) T A N K P ❑ Appr ed Approved with conditions El Disapproved L ee Attachment With Conditions) A lipN Plan Reviewers Name Date APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQ N COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." D Awlicant's Signature (�f r"�- _ Title Authorized Agent Date 2/3/15 BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. NAME Carl Wayne Henderson TITLE President PHONE # (209) 467-7573 PO Box 31325 - Stockton, CA 95213 SIGNATURE ( �� l�--.�� DATE 2/3/15 EH230038 (revised 02/20/09)