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ENVIRONMENTAL HEALTH DEPAAttfIVED <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 DEC 2 8 2016 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TINVIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT 'DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT 5d PIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Veronica Freitas 916-373-1166 <br /> A <br /> C Facility Name Olympian Flyers#427 Phone# 916-373-1166 <br /> I Address 3300 Waterloo Road, Stockton, CA 95205 <br /> L <br /> T Cross Street Report Ave. <br /> Y Owner/Operator Flyers Energy,LLC I Phone# 530-885-0401 <br /> o Contractor Name Walton Engineering, Inc. Phone# 916-373-1168 <br /> T Contractor Address P.O. Box 1025,West Sacramento, CA CA Lic# 617238 Class A,B Haz <br /> R See Attached A Insurer Work Comp# <br /> C <br /> T ICC Technician's Name Expiration Date <br /> o <br /> R ICC Installer's Name Expiration Date <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 87 Leak Detector <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S ttachment With Conditions) <br /> A <br /> N Plan Reviewers Name j Date ,447 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA TH 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 Title Const COord. Date 12/28/16 <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 Const Cnord- PHONE# 916-373-1167 <br /> ADDRESS P.O. Box 1025,West Sacramento, CA 95691 <br /> SIGNATURE DATE <br /> EH230038(revised 10/30/12) <br /> 2 <br />