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ENVIRONMENTAL HEALTH DEPARTMENT n <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 GRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Veronica Fre' as 916-373-1167 <br />A <br />c <br />Facility Name Olympian Flyers #427 <br />Phone # 9 -373-1167 <br />I <br />L <br />Address 3300 Waterloo Road <br />I <br />T <br />Cross Street Report Ave. <br />Y <br />Owner/Operator Flyers Energy, LLC <br />Pho e# 530-885-0401 <br />C <br />Contractor Name Walton Engineering, Inc. <br />Pone # 916-373-1168 <br />T <br />Contractor Address P.O. Box 1025, West Sacramento, CA <br />CA Lic # 17238 Class A,B, Haz <br />A <br />Insurer BE Insurance CorpWork <br />Comp # WC4000674 <br />TICC <br />Technician's Name <br />Expiration Date <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />hemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />Tank Field Wiring <br />A <br />N <br />K <br />P <br />❑ Approved❑ pproved with conditions ❑ Disapproved <br />L <br />(See ttachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WIT 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 PER IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." C TRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHIC THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature Title Const Coord. Date 02/11/14 <br />/ BILLING INFORMATION: <br />Indicate the responsible party to be illed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is djfferent than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by sigriature and date below. <br />NAME Veronica Freitas TITLE Const COord PHONE # <br />ADDRESS P.O. Box 1025, West Sacramento, CA 95691 <br />SIGNATURE 1L DATE 02/11/2014 <br />EH230038 (revised 10/30/12) <br />2 <br />