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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 # CAR000142463 Project Contact & Telephone # Sarah Jablonsky - 916- 373- 1165 <br /> � <br /> Facility Name Speedway #4873 Phone # <br /> L <br /> Address 35 North Cherokee Lane , Lodi , CA 95240 <br /> T Cross Street E . Elm St . <br /> Y Owner/Operator Speedway LLC Phone # <br /> C Contractor Name Walton Engineering , Inc . Phone # 916-373- 1165 <br /> 0 <br /> N Contractor Address PO Box 1025 , West Sacramento , CA 95691 CA Lic # 617238 class A , B , Haz <br /> T <br /> A Insurer Service American Indemnity Company Work Comp # SAMTWC10020100 <br /> T ICC Technician 's Name David Delgado - 5246959 Expiration Date 11 / 15/2023 <br /> ° ICC Installer's Name David Delgado - 5246959 Expiration Date 10/07/2024 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T 87 Line Repair <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 4 .t Date //7 �O �/2O 22 <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 Title Construction Manager Date 09/ 19/2023 <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- 1 165 <br /> ADDRESS PO BOX 1025 , West Sacramento , CA 95691 <br /> SIGNATURE �cr�tl�G �{a6�ey DATE 09/ 19/2023 <br /> 2of6 <br />