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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 /> C Facility Name Speedway#4873 Phone# <br /> I Address35 North Cherokee Lane, Lodi, CA 95240 <br /> L <br /> I Cross Street E. Elm St. <br /> T <br /> Y Owner/Operator Speedway LLC Phone# <br /> C Contractor Name Walton Engineering, Inc. Phone#916-373-1165 <br /> N <br /> T Contractor Address PO Box 1025 West Sacramento CA 956911 CA Lic# 617238 Class A B Haz <br /> A Insurer Service American Indemnity Company Work Comp#SAMTWC 10020100 <br /> T ICC Technician's Name David Delgado - 5246959 Expiration Date 11/15/2023 <br /> R 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 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 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#916-373-1165 <br /> ADDRESS PO BOX 1025, West Sacramento, CA 95691 <br /> SIGNATURE �CIizCLiL �l �e DATE 09/19/2023 <br /> 2of6 <br />