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SANJOAQUIN Environmental Health Department --- COUNTY — - APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE , INDICATE PERMIT TYPE BELOW: ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE F EPA Site # CAL000460580 -_ Project Contact & Telephone # Abigail Jara / 661 -250 - 9300 A C Facility Name Tesoro ( Speedway) #68154 Phone # Forth is Project: 661 -250-9300 1 Address 2500 W Lodi Ave , Lodi , CA 95242 L T Cross Street S Lower Sacramento Rd Y Owner/Operator Western Refining Retail LLC Phone # For this Project: 661 -250-9300 o Contractor Name Walton Engineering , Inc Phone # For this Project: 661 -250-9300 T Contractor Address 3900 Commerce Drive CA Lic # 617238 Class A, B , HAz A Insurer TLB Insurance Services Work Comp # SAMTWC10020101 T ICC Technician's Name Jim H Cossey Expiration Date 2/ 13/2025 QICC Installer' s Name Jim H Cossey Y Expiration Date 2/ 13/2025 Tank system work area Tank Size Chemicals Stored Currently Date UST (I ,e, 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed T All Line Leak Detectors F00 (2) , 6 , 000(2) Unleaded Products & Diesel 10/ 1 /1997 A N K P ❑ Approved LApproved with conditions ❑ Disapproved L e Attachment With Conditions ) N Plan Reviewers Name Date APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: " I CERTIFY THAT IN 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA," CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: " I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." py/ Applicant's Signature / Title Authorized Agent Date 7/ 16/2024 BILLING INFORMATION : Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank . If the party designated below is different than the permit applicant , e . g . property owner, the party must acknowledge this responsibility for the billing by signature and date below, NAME A&S Engineering TITLE Authorized Agent PHONE # 661 -250 -9300 ADDRESS 28405 Sand Canyon Rd Suite B , Canyon Country , CA 91387 SIGNATURE O� �ZCU DATE 7/ 16/2024 2of6