Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> COUNTY SEp 0 6 2022 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK / !RONMENTAL HEALTH <br /> FRMiT � sERvlcEs <br /> RETROFIT OR PIPING REPAIR PERMIT ' <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> � Facility Name Speedway # 1486 Phone # <br /> I Address 13975 E . Hwy88 Lockeford CA 95237 <br /> L <br /> TCross Street Cherry Street <br /> Y Owner/Operator Speedway LLC Phone # <br /> o Contractor Name Walton Engineering , Inc . Phone # <br /> N <br /> T Contractor Address PO Box 1025 , West Sacramento , CA 956911 CA Lic # 617238 Class Ar Bo Haz <br /> A Insurer State Compensation Insurance Fund Work Comp # 9113339 <br /> T ICC Technician ' s Name David Delgado #5246959 Expiration Date 11 / 15/2023 <br /> R ICC Installer' s Name FFS Cert- David Delgado # 1006483709 Expiration Date 12/03/23 <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 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( e tachment With Conditions) <br /> N ZZI y Z <br /> Plan Reviewers Name �' Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANC ITH 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 �AiC � Title Manager Date09/02/2022 <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 , a&aw DATE 09/02/2022 <br /> 2 of 6 <br />