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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 H & S Energy #3081 Phone # <br /> I <br /> L Address 6633 Pacfic Ave <br /> T Cross Street 18th Ave . <br /> Y Owner/OperatorH & S Energy Phone # <br /> o Contractor Name Walton Engineering , Inc . Phone # 916- 373 - 1165 <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 # SAMTWC10020100 <br /> T ICC Technician ' s Name David Delgado Expiration Date 11 / 15/2023 <br /> R ICC Installer's Name David Delgado Expiration Date 10/07/2023 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i. e. 87 piping sump, 91 leak detector, UDC 112 , etc. ) Installed <br /> T No Changes <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name ' Dated <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 Title Construction Manager Date 05/23/2023 <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 a&a4oL Clio, 61_ DATE 05/23/2023 <br /> 2 of 6 <br />