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SANJOAQUIN 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 REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Kristin Nappen 916-373- 1165 <br /> A <br /> C Facility Name Speedway #4681 Phone # <br /> � Address 2500 W. Lodi Avenue Lodi CA 95242 <br /> i Cross Street <br /> T <br /> Y Owner/Operator Speedway LLC Phone # <br /> o Contractor Name Walton Engineering , Inc . Phone # 916 .373. 1165 <br /> T Contractor Address P . O . Box 1025 West Sacramento CA 95691 CA Lic # 617238 class A B Haz <br /> A Insurer Attached Work Comp # <br /> TICC 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 /> (i .e. 87 piping sump, 91 leak detector, UDC 112 , etc.) Installed <br /> T Replace 91 Drop Tube <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A ^ � <br /> N Plan Reviewers Name ^ , " S0 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 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 COMPENSATI N S OF CALIFORNIA. " CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY <br /> THAT IN THE PERFORM C OF THE WO FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA. " <br /> Applicant's SignatureW4 Title Contractor Date d '� <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 Kristin Nappen TITLE Contractor PHONE # 916-373 - 1165 <br /> ADDRESS P . O . Bo 1025 , West Sacramento , CA 95691 <br /> SIGNATURE DATE Cl " j �9 <br /> 2of6 <br />