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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 /> El TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT 11 COLD START/EVR UPGRADE <br /> F EPA Site # CAL000104482 Project Contact & Telephone # Sarah Jablonsky-Const . Mngr, 916-373- 1165 <br /> A <br /> C Facility Name Pacific Car Wash Phone # 209-478-5504 <br /> I Address <br /> � 4415 Pacific Ave . , Stockton , CA 95207 <br /> TCross Street Bianchi Rd , <br /> Y Owner/Operator STHEM , LLC Phone # 510-268-8500 <br /> C o Contractor Name Walton Engineering <br /> Phone # 916-373- 1165 <br /> N Contractor Address PO Box 1025 , West Sacramento , CA 95691 <br /> T CA Lic # 617238 Class A , B , HAZ <br /> AInsurer State Fund <br /> Work Comp # 9113339 <br /> ' <br /> ICC Technician 's echnicians Name <br /> T Tom Sanford No . 8965603 Expiration Date 06/09/21 <br /> QICC Installer's Name <br /> R Rafael Flores No . 8712762 Expiration Date 2/ 14/21 <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.) y Installed <br /> T N/A 12K 87 Gasoline 9/22/ 1999 <br /> N N/A 8K <br /> 91 Gasoline 9/22/ 1999 <br /> K <br /> P ❑ ApprovedApproved with conditions ❑ Disapproved <br /> L ( <br /> A ee Attachment With Conditions) <br /> N Plan Reviewers Name � C" <br /> � Date_ U <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 SignatureW\ZAVAA Title Construction Manager Date 06/26/20 <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 parry 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 �� ��� DATE 06/26/20 <br /> 2of6 <br />