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SANJOAQUIN Environmental Health Department <br /> - - <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 REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # CAL000460641 Project Contact & Telephone # Abigail Jara / 661 -250 - 9300 <br /> A <br /> C Facility Name Tesoro ( Speedway ) #68221 Phone # For this Project : 661 -250-9300 <br /> 1 Address 2705 Country Club Blvd , Stockton , CA 95204 <br /> L <br /> T Cross Street N Ryde Ave <br /> Y Owner/Operator Western Refining Retail LLC Phone # For this Project : 661 -250-9300 <br /> o Contractor Name Walton Engineering Inc Phone # For this Project: 661 -250 -9300 <br /> N Contractor Address 3900 Commerce Drive CA Lic # 617238 Class A, B , HAZ <br /> T <br /> AInsurer TLB Insurance Services Work Comp # SAMTWC10020101 <br /> T ICC Technician 's Name Jim H Cossey Expiration Date 2/ 13/2025 <br /> R ICC Installer's Name Jim H Cossey Expiration Date 2/ 13/2025 <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 All Line Leak Detectors 12,000 (1 )28,000(1 ) 4,000 ( 1 ) Unleaded Products & Diesel 1 / 1 /1996 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L hie At achment With Conditions) <br /> A <br /> N Plan Reviewers Name -C Date �7/ 3 � /2 <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 Signatur L".*ttt Title Authorized Agent Date 7/ 16/2024 <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 A& S Engineering TITLE Authorized Agent PHONE # 661 -250 -9300 <br /> ADDRESS 28405 Sand Canyon Rd Suite B , Canyon Country , CA 91387 <br /> SIGNATURE DATE 7/ 16/2024 <br /> 2 of 6 <br />