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SANJOAQUIN Environmental Health Department <br /> - - - COUNTY — <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/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Veronica Freitas 916-373- 1166 <br /> A <br /> C Facility Name Flyers #427 Phone # 530-885-0401 <br /> Address <br /> L 3300 Waterloo Road Stockton CA 95205 <br /> Cross Street <br /> T <br /> Y Owner/Operator Flyers Energy , LLC Phone # 530-885-0401 <br /> C Contractor Name Walton Engineering , Inc. Phone # 916-373- 1166 <br /> N Contractor Address CA Lic # Class <br /> T P . O . Box 1025 West Sacramento CA 95691 617238 AB HAZ <br /> R Insurer Work Comp # <br /> A See Attached <br /> TICC Technician ' s Name Robert Bush Expiration Date <br /> R <br /> 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 JAee Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date 2 1 �7 ZU 'ZI <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 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 co^1 '\ co' , Date <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 date below. <br /> NAME Veronica Freitas TITLE contractor PHONE # 916-373- 1166 <br /> ADDRESS P . O , Box 1025 West Sacramento CA 95691 <br /> SIGNATURE DATE ` ) J ) " /31 <br /> 2 of 6 <br />