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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 /> C Facility Name Speedway #4612 Phone # 209-369 -3124 <br /> I Address 2448 West Kettleman Lane , Lodi , CA 95242 <br /> T Cross Street Lower Sacramento Road <br /> Y Owner/Operator Speedway , LLC Phone # <br /> C Contractor Name Walton Engineering , Inc . Phone # 916-373 - 1165 <br /> O <br /> N Contractor Address PO Box 1025 , West Sacramento , CA 956911 CA Lic # 617238 Class A , B , HAZ <br /> T <br /> A Insurer State Fund Work Comp # <br /> T <br /> T ICC Technician 's Name Expiration Date <br /> Q ICC Installer's Name p <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 1/2, etc.) Installed <br /> T Drop Tube 10K 87 <br /> A Drop Tube 10K 91 <br /> K Drop Tube 10K Diesel <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L (S Aft hment With Conditions) ^ , 12W A v�// <br /> N Date <br /> Plan Reviewers Name <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 k&MV Title Construction Manager Date <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 bin DATE 00 16 I ZD <br /> 2 of 6 <br />