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SAN JOAQUIN Environmental Health Department <br /> - COUNTY <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 # <br /> A <br /> C Facility Name Speedway #6187 Phone # 916-373- 1165 <br /> 1 Address <br /> L 2705 Country Club Stockton CA 95204 <br /> 1 Cross Street N . Ryde Ave . <br /> T <br /> Y Owner/Operator Speedway , LLC Phone # <br /> C Contractor Name Phone # 916-373- 1165 <br /> Q Walton Engineering , Inc. <br /> N Contractor Address PO Box 1025 , West Sacramento , CA 95691 CA Lic # 617238 <br /> T Class A , 13 , HAZ <br /> R <br /> A Insurer State Fund Work Comp # <br /> T <br /> T ICC Technician ' s Name Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T Drop Tube 8K 91 Gasoline No Change <br /> A Drop Tube 4K Diesel No Change <br /> N <br /> K <br /> P ❑ Approved eApproved with conditions ❑ Disapproved <br /> L ( e achment With Conditions) <br /> A F _ p <br /> N ro <br /> Plan Reviewers Name Date. S)/24 <br /> 24 2� <br /> r— <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 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 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 Signature kam& Title Construction Manager Date On <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 Sarah Jablonsky TITLE Construction Manager PHONE # 916-373- 1165 <br /> ADDRESS PO Box 1025 , West Sacramento , CA 95691 <br /> SIGNATURE b&WV DATE t ' a ' 1k) <br /> 2 of 6 <br />