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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 REPAIR/ RETROFIT ❑ COLD START/ EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> � Facility Name Speedway #6187 Phone # <br /> I Address 2705 Country Club Blvd . , Stockton , CA 95204 <br /> L <br /> I Cross Street N . Ryde Ave . <br /> T <br /> Y Owner/Operator Speedway LLC Phone # <br /> C Contractor Name Walton Engineering Inc . Phone # 916- 373- 1165 <br /> D 9 9 <br /> T Contractor Address PO Box 1025 , West Sacramento , CA 95691 CA Lic # 617238 Class A , B , Haz <br /> A InsurerService American Indemnity Company Work comp # SAMTWC10020101 <br /> T ICC Technician ' s Name David Delgado No . 5246959 Expiration Date 10/20/2025 <br /> R ICC Installer' s Name David Delgado No . 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 Drop Tube 8K 91 Gasoline No Change <br /> A Drop Tube 4K Diesel No Change <br /> N <br /> K <br /> P ❑ Approved Lid Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name J ; o Date 1 .2 103 lu .23 <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 11 /20/2023 <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- 1165 <br /> ADDRESS PO Box 1025 , West Sacramento , CA 95691 <br /> SIGNATURE �Qit �lG �Brta,�y DATE <br /> 2 of 6 <br />