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SANJOAQUIN Environmental Health Department <br /> COUNTY -- - EC ` <br /> Ei V E <br /> APPLICATION FOR UNDERGROUND STORAGE TANKB 0 2 2023 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMITS I0 ENTAL HEALTH <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD s�V1VR'00QbE <br /> F EPA Site # Project Contact & Telephone # <br /> A <br /> Facility Name H &S Energy #3081 Phone # <br /> I <br /> L Address 6633 Pacfic Ave <br /> TCross Street <br /> Y Owner/OperatorH &S Energy Phone # <br /> C Contractor Name Walton Engineering , Inc . Phone # <br /> T Contractor Address PO Box 1025 , West Sacramento , CA 95691 CA Lic # 617238 Class A , B , Haz <br /> A InsurerService American Indemnity Company Work comp # SAMTWC1 0020100 <br /> T ICC Technician 's NameAnthony Reyes No . 8293772 Expiration Date 08/ 12/2023 <br /> R ICC Installer's NameAnthony Reyes No . 8293772 Expiration Date 09/28/2024 <br /> Tank system work areaTank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ee tachm nt With Conditions) <br /> N Plan Reviewers Name Date <br /> 21 ) 623 <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. " _cls <br /> Applicant's Signature ` ' � Title Construction Manager Date 02/02/2023 <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 73d,4,ao DATE <br /> 02/02/2023 <br /> 2 of 6 <br />