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SANJOAQUIN Environmental Health Department <br /> - - cou1\lTY - -- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> 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 REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone #Janelle Dockham - 661 -631 -3870 <br /> � <br /> Facility Name FastLane Central Valley <br /> Phone # 707-431 - 351 1 <br /> I <br /> L Address 116 Roth Road , Lathrop CA 95330 <br /> T Cross Street S . Harland <br /> Y Owner/Operator BG Group . Hardeep GIII Phone # 707- 431 - 3511 <br /> o Contractor Name Nwestco LLC Phone # _ _ 3870 <br /> T Contractor Address 2209 Zeus Court , Bakersfield , CA 9330 CA Lic # 1073967 pz C61 / D40 <br /> A Insurer Ohio Casualty Insurance Company Work Comp # XWS57384241 <br /> T <br /> T ICC Technician 's Name Ronald Clark Expiration Date 05/04/2024 <br /> R ICC Installer's Name Ronald Clark Expiration Date 05/04/2024 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc, ) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se) Attachment With Conditions ) <br /> Aodokl <br /> Z <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 TO <br /> WORKER'S 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 /> Applicant's Signatur Dacle,Fr� Title Perimit Clerk Date 05/24/2022 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g , property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Janelle Dockham TITLE Permit Clerk PHONE # 661 -631 - 3870 <br /> ADDRESS 2209 Zeus Court , Bakersfield , California 93308 <br /> SIGNATURE 9 ! � DATE 05/24/2022 <br /> 2 ol` 6 <br />