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SANJOAN N Environmental Health Department <br />j--CQUNTY <br />l 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 />0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Veronica Freitas 916-373-1166 <br />A <br />C <br />Facility Name Phone # <br />Y Flyers #427 530-885-0901 <br />t <br />L <br />Address 3300 Waterloo Road Stockton CA 85205 <br />1 <br />T <br />Cross Street <br />Y <br />Owner/Operator Flyers Energy, LLC <br />Phone # 530-885-0401 <br />o <br />Contractor Name Walton En ineerin Inc. <br />Phone # 916-373-1166 <br />N " <br />T <br />Contractor Address P.O. Box 1025 West Sacramento. CA 95691 <br />CA LIG # Class <br />617238 AB HAZ <br />R <br />A <br />Insurer See Attached <br />Work Comp # <br />T[CC <br />Technician's Name Robert Bush <br />Expiration Date <br />R <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />UDC <br />Tank Size <br />Chemicals Stored Currently <br />Gate UST <br />Installed <br />0.e. 87 pwm s"A 91 leak detector, W. eta) <br />87 Leak Detedor <br />A <br />N <br />IC <br />P <br />❑ Approved Approved with Conditions ❑ Disapproved <br />L <br />ape Attachment With Conditions) <br />A <br />17N I '7-0 2-1 <br />Plan Reviewers Naive Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />OAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: `I CERTIFY THAT IN <br />WORK FOR WHICH THIS PERMIT IS ISSUED, t SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />THE PERFORMANCE OF THE <br />RKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 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 />F CALIFORNIA," <br />ff <br />tt <br />ppllcant'sSlgnatare a!�/lu._-__ Tito <br />BILLING INFORMATION: <br />Indicate.the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must <br />acknowledge this responsibility for the billing by signature and data below. <br />NAME Veronica Frellas TITLE PHONE # 916-373.1166 <br />ADDRESS P.O. Box 1025 West Sacramento CA 95691 <br />SIGNATURE DATE WIL11 / <br />31 <br />2of6 <br />