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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 />❑ TANK RETROFIT NPIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Veronica 916-373-1167 <br />C <br />Facility Name 01 i an #487 <br />Phone # 1401_ <br />I <br />L <br />Address <br />983 M f fat Blvd. Mantpca, CA 25336 <br />1 <br />Cross Street <br />T <br />Y <br />Owner/Operator Fl ers Energy, LLC <br />Phone # <br />C <br />N <br />Contractor Name <br />Inc. <br />Phone #. 916-373-1167 <br />T <br />Contractor Address <br />P.O. Box 1025 . WSacram nto <br />CALic# 617238 Class <br />AB T4az <br />AInsurer <br />C <br />QBE Insurance Cor <br />Work Comp#QWC4000674 <br />T <br />ICC Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />87 MLLD <br />A <br />N <br />K <br />P <br />Approved Approved with conditions Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <br />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 <br />PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." ­1� <br />Applicant's Signature . l/, Title C nn c t <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 ngin rin_F Inc TITLE Contractor -PHONE #_916-"_73-12L3 <br />ADDRESS <br />SIGNATURE <br />EH230038 (revised 10/30/12) <br />2 <br />