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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 REPAIR/ RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Penn Tanner 775-813-4611 <br /> A 800-899-2376 <br /> Facility Name FlyersCFN Phone # <br /> I Address 983 Moffet Blvd . Manteca , CA 95336 <br /> L <br /> I Cross Street Cowell Ave <br /> T <br /> Y Owner/Operator Flyers Energy Phone # 800-899-2376 <br /> C Contractor Name L .A. Perks Petroleum Specialists Phone # 775-358-4403 <br /> 0 <br /> N Contractor Address 765 East Greg Street CA Lic # 678948 Class A , C-36 , HAZ <br /> T <br /> R <br /> A Insurer Insurance co . of the west Work Comp # WLD169920719 <br /> C <br /> T ICC Technician ' s Name Robert Alfers Expiration Date 12-2- 19 <br /> 0ICC Installer' s Name Jack H Healy Expiration Date 8- 13-20 <br /> R <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 <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L e Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date UL 1 0, <br /> APPLICANT MUST PERFORM ALL WORK IN' -k ORDANG 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 ,O`^- I �----� Title <br /> Planning Date 12-3- 18 <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 Penn Tanner TITLE Design PHONE # 775-358-4403 <br /> ADDRESS 765 East Greg St, Sparks , NV 89431 <br /> SIGNATURE DATE 12-4- 18 <br /> 2 of 6 <br />