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, AN 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 /> A <br /> c Facility Name H &S ENERGY #3084 Phone # <br /> I Address <br /> L 3940 N . TRACY BLVD TRACY , CA 95304 <br /> Cross Street <br /> T W. LARCH RD <br /> Y Owner/Operator H & S ENERGY Phone # 916-738- 1818 <br /> C Contractor Name <br /> o WALTON ENGINEERING INC Phone # 916-343-3857 <br /> N <br /> T 617238 Class Contractor Address 3900 COMMERCE DRIVE WEST SACRAMENTO , CA 95691 CA LIC # A, B , HAZ <br /> R Insurer Service American Indemnity Company A ry P Y Work Comp # SAMTWC10020102 <br /> cICC Technician 's Name <br /> T Michael Raymond Expiration Date 04/01 /2025 <br /> RICC Installer' s Name <br /> Tom Sanford Expiration Date 09/26/18 <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc, ) y Installed <br /> T New low voltage wire in tank area <br /> A <br /> N New manwa s <br /> K <br /> P ❑ Approved IVApproved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions ) <br /> A I <br /> N Plan Reviewers Name ' � 5y Date 131202- Y <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 s c 'GR.i''Ir s*/ Title Operations Coordinator Date 09/26/2024 <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 Stephanie Charissa TITLE Operations Coordinator PHONE # 916- 343- 3857 <br /> ADDRESS PO Box 1025 West Sacramento , CA 95691 <br /> SIGNATURE_ SL8L lh"Vwy DATE 09/26/2024 <br /> 2 of 6 <br />