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SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT R UDC REPAIRIRETROFIT 0 COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Veronica Freitas - 916-373-1167 <br />A <br />c <br />Facility Name Ol m iam #427 <br />Phone # 530-885-0401 <br />I <br />� <br />Address 3300 Waterloo Road <br />I <br />T <br />Cross Street Report Ave <br />Y <br />Owner/Operator FIvers Energy, LLC. <br />Phone # <br />o <br />Contractor Name Walton Engineering, Inc. <br />Phone # 916-373-1167 <br />T <br />Contractor Address P.O. Box 1025 <br />CA Lic # 617238 Class A, B, Haz <br />A <br />Insurer Attached <br />Work Comp # <br />ICC Technician's Name <br />Expiration Date <br />RICC <br />Installers Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDc 1/2, etc.) <br />Installed <br />T <br />UDC #6 Shear Valve <br />A <br />N <br />K <br />P <br />❑ Approved <br />roved with conditions ❑ Disapproved <br />L <br />(See Attachment . h Conditions) <br />A <br />a <br />N <br />Plan Reviewers Name I <br />— Date lea,) I <br />APPLICANT MUST PERFORM ALL RK IN ACCO ANCE <br />TH SAN JOAQ N COU ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR L ENSED GENTS SIGNATURE CERTIFIES THE FOLLOWING: °I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SH 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 <br />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 />v' <br />Applicant's Signature <br />Title Contractor Date 05/30/14 <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME Veronica Freitas TITLE Contractor PHONE # 916-373-1167 <br />ADDRESS P.O. Box 1025, West Sacramento, CA 95691 <br />SIGNATURE °" DATE 05/30/14 <br />EH230038 (revised 10/30/12) <br />Ii <br />