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t <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 ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility Name Fast Lane <br />Phone # 209 234-4341 <br />I <br />L <br />Address '116 E Lathrop Rd Lathrop 95330 <br />I <br />Cross Street <br />Y <br />Owner/Operator <br />Phone # 209 234-4341 <br />C <br />Contractor Name Service Station Testing - SST INC <br />Phone # (209) 465-5577 <br />N <br />T <br />Contractor Address PO Box 31465 - Stockton, CA 95213 <br />CA Lic # 962520 Class A /13 / C-� 0,2o,3s <br />RInsurer <br />A <br />EXEMPT <br />Work Comp # N/A <br />T <br />IGC Technician's Name Carl Wayne Henderson (5252923) <br />Expiration Date 08/10/2014 <br />o <br />R <br />ICC Installer's Name N/A <br />Expiraiion.Dafe N/A, <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.$ 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />T <br />A <br />N <br />K <br />P <br />❑ Approved .Approved with conditions ❑ Disapproved <br />L <br />(See A chment With Conditions) <br />A <br />N `' <br />�. <br />Plan Reviewers Name Date 13 %3 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUt4TY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S 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 1N SUCH A MANNER AS TO BECOME SUBJECT <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />;TO <br />THAT IN THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT Is ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature L -- Tide Authorized Agent Date 11/13/13 <br />I:SILLIIVV IIVrVtCIVIliI IVIv. <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 Carl Wayne Henderson TITLE President PHONE # (209) 467-7573 <br />ADDRESS PO Box 31325 - Stockton, CA 95213 <br />SIGNATURE ��-�p L-- —DATE 11/13/13 <br />EH230038 (revised 02/20/09) <br />1 <br />