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SAN JOAQUIN EnvironmenRf j h EWe t1r D <br /> COUNTY--- <br /> JAN 17 2024 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br /> PERMIT/ SERVICES <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 # Veronica Freitas 916 - 373- 1166 <br /> C Facility Name H &S Energy #3035 Phone # <br /> I Address 192 Lathrop Rd . , Rd . , Lathrop , CA 95330 <br /> L <br /> I Cross Street S . Harlan Rd . <br /> T <br /> Y Owner/OperatorH & S Energy Phone # <br /> C Contractor Name Walton Engineering , Inc Phone # 916- 373- 1166 <br /> O <br /> N Contractor Address P . O . Box 1025 , West Sacramento , CA 956 1CA Lic # Class AB Haz <br /> T <br /> R <br /> A Insurer See Attached Work Comp # <br /> C <br /> T ICC Technician 's Name See Attached Expiration Date <br /> Q <br /> R ICC Installer' s Name Expiration Date <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.) Installed <br /> T Diesel Drop Tube <br /> A <br /> N <br /> K <br /> P ❑ Approved � Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A j <br /> N Plan Reviewers Name '� - - Date r � 1 <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 <br /> Compliance Manager Date 1 / 17/2024 <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 . Box 1025 , West Sacramento , CA 95691 <br /> SIGNATURE DATE 1 / 17/2024 <br /> 2 of 6 <br />