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• <br />• <br />ENVIRONMENTAL HEALTH DEPARTMENT <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 NPIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Veronica 916-373-1167 <br />A <br />C <br />Facility Name Ol i an #487 <br />Phone # 530-88S-0401 <br />I <br />L <br />Address Moffat Blvd.,Manteca, A 36 <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator Flyers Energy, LLC <br />Phone # <br />C <br />o <br />Contractor Name Walton Engineering, Inc. <br />Phone # 916-373-1167 <br />N <br />T <br />Contractor Address P.O. Box 102 <br />W. Sacramento <br />CA Lic # Class <br />617238AB Haz <br />RInsurerork <br />A <br />QBE Insurance CorpCP <br />Com # QWC4000674 <br />TICC <br />Technician's Name <br />Expiration Date <br />RICC <br />Installer's 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 />87 MLLD <br />A <br />N <br />K <br />P <br />Approved <br />Approved with conditions Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date �{/L o�i� Date (7- 2t -F — Z003 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH <br />SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN <br />COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. <br />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 . <br />Title Const. Coordinatar Date <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 Walton Engineering, Inc, TITLE Contractor PHONE# 916-373-1167 <br />ADDRESS <br />SIGNATU <br />EH230038 (revised 10/30/12) <br />2 <br />