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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 600 East Main Street,. Stockton; California 95202 Telephone: (209) 468-3420 Fax: (209) 468-3433 APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT 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 # � Faciliity Name Fast Lane Phone # 209 234-4341 I L Address '116 E Lathrop Rd Lathrop 95330 Cross Street T Y Owner/Operator Phone # 209 234-4341' C 0 Contractor Name Service Station Testing - SST INC Phone # (209) 465-5577 N r Contractor Address PO Box 31465 - Stockton, CA 95213 CA Lic # 962520 Class A /B / C-1 0,20,36 R A Insurer EXEMPT Work Comp # N/A T ICC Techhician's Name Carl Wayne Henderson (5252923) Expiration Date 08/10/2014 0ICC R Installer's Name N/A Expiration Date N/A. Tank system work area Tank Size Chemicals Stored Currently Date UST Installed (i.S 87 piping sump, 91 leak detector, UDC 112, etc.) T A N K a - ❑ Approved ❑ Approved with conditions ❑ Disapproved p L (See Attachment With Conditions) A N " Plan Reviewers Name Date APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN; THE PERFORIMANCE' 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.' - �1 Title Authorized Agent pate 11 /13/13 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 patty, must acknowledge this responsibility for -the billing by signature and date below. NAME Carl Wayne Henderson TITLE' President PHONE # (209) 467-7573 ADDRESS PO Box 31325 -/ Stockton, CA 95213 SIGNATURE `l �-- iY(1— DATE 11113/13 EH230038 (revised 02/20/09)