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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 /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ja COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Veronica Freitas 916 -373- 1166 <br /> A <br /> C Facility Name Speedway #4612 Phone # <br /> I Address L Add2448 W. Kettleman Lane Lodi CA 95242 <br /> I Cross Street S . Lower Sacramento Rd , <br /> T <br /> Y Owner/Operator Speedway LLC Phone # <br /> o Contractor Name Walton Engineering , Inc Phone # 916 - 373 - 1166 <br /> N Contractor Address CA Lic # 617238 Class AS Haz <br /> T P . O . Box 1025 West Sacramento CA 95691 <br /> R Insurer Work Comp # <br /> C ICC Technician 's Name Expiration Date <br /> T See Attached <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (I o. 87 piping Sump, 81 leak dotoctof- UDC 1R. etc ) Installed <br /> T 87 Drop Tutor <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions Disapproved <br /> L ( See Attachment With Conditions) <br /> N <br /> Plan Reviewers Name ) Date <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 AGENTS 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. " Dl <br /> Applicant'sSignalure { � ' � Title !`(�((1Q�1 �� li(�YY1pPjr Date 12/ i 7 / � <br /> --- -- <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 Veronica Freitas TITLE Compliance Manager PHONE # 916 - 373 - 1166 <br /> ADDRESS P • O . IBox 1025 , West Sacramento , CA 95691 / <br /> SIGNATURE 6 DATE <br /> 2of6 <br />