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SAN JOAQUIN Environmental He tr De ar ,7ent, <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK 7 2072 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> WIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW( ' 01T / n r V�IVICES <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> � Facility Name H & S Energy #3084 Phone # <br /> I Address 3940 N . Tracy Blvd . , Tracy , CA 95304 <br /> T Cross Street W. Larch Rd , <br /> Y Owner/Operator H & S Energy Phone # 916- 285J402 <br /> C Contractor Name Walton Engineering , Inc . Phone # 916- 373- 1165 <br /> ."r Contractor Address PO Box 1025 , West Sacramento , CA 95691 FCA Lie # 617238 Class A , B , Haz <br /> A InsurerService American Indemnity Company Work Comp # SAMTWC10020100 <br /> T <br /> T ICC Technicians Name 9' David Delgado Expiration Date 10/07/2024 <br /> R ICC Installer's Name David Delgado Expiration Date 11 / 19/2024 <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 911 sb�rf gulp V 0 000 GI II 1 I qi I <br /> N DIgWI twg7 `t STr 3 �A11 � iU ; QOQ Pik"O II / I � I �I <br /> K Df usQj V;� Qtcj1 STP sQt'h Au , uvv Dlq ` QQl <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A ^ n ry <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 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 c5a.a/ Title Construction Manager Date 11 /04/2022 <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 Sarah Jablonsky TITLE Construction Manager PHONE # 916- 373- 1165 <br /> ADDRESS PO Box 1025 , West Sacramento , CA 95691 <br /> SIGNATURE c5aAav*i DATE 11 /04/2022 <br /> 2 of 6 <br />