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SANJ O A Q U I N 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 /> Xl TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Brian Able - 408-938-7116 <br /> A <br /> Facility Name Speedway 4612 Phone # 209-369-3124 <br /> I <br /> L Address 2448 W Kettleman Lane Lodi <br /> Cross Street Lower Sacramento <br /> T <br /> Y Owner/Operator Speedway LLC Phone # 209-369-3124 <br /> G Contractor Name Service Station Systems Inc. Phone # 408-971 -2445 <br /> o _ <br /> T Contractor Address 680 Quinn Ave. San Jose, CA 95112 CA Lic # 485184 Class B/C-61 /D40/Haz <br /> A Insurer SCF National Insurance Company Work Comp # 4046603 <br /> C ICC Technician's Name Expiration Date 7/22/2024 <br /> T Kris Bell <br /> R ICC Installer's Name Kris Bell Expiration Date 7/22/2024 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 teak detector, UDC 112, sic.) Installed <br /> T <br /> A <br /> N — <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> n � 7,7 �+ <br /> N Plan Reviewers Name Date J L ' LL <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 Project Manager Date 5/30/2023 <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 Brian Able TITLE Project Manager PHONE # 408-938-7116 <br /> ADDRESS 680 Quinn Ave . San Jose CA 95112 <br /> SIGNATURE <br /> DATE 5/30/2023 <br /> 2of6 <br />