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SAN 10 A Q U I N 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 # Sarah Jablonsky- Const , Mngr. 916-373- 1165 <br /> A <br /> C Facility Name Flyers #427 Phone # <br /> I <br /> L Address 3300 Waterloo Rd . , Stockton , CA 95205 <br /> TCross Street Report Ave . <br /> Y Owner/Operator Flyers Energy, LLC Phone # <br /> C Contractor Name Walton Engineering , Inc. Phone # <br /> 0 9 9 , <br /> N Contractor Address PO Box 1025 , West Sacramento , CA 95691 CA Lic # 617238 <br /> T Class A , B , HAZ <br /> AInsurer State Compensation Insurance Fund Work Comp # 9113339 <br /> T ICC Technician 's Name Rafael Flores Cert# 8712762 Expiration Date 01 /26/23 <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T Tank #2 10K Gasoline 87 <br /> A Tank #3 10K Red Diesel <br /> N <br /> K Tank #4 10K Diesel <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( etac ment With Conditions) <br /> A <br /> N Plan Reviewers Name.\,NDate / <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE ITH 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 Construction Manager 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 Sarah Jablonsky TITLE Construction Manager PHONE # 916-373- 1165 <br /> ADDRESS PO Box 1025 , West Sacramento , CA 95691 <br /> SIGNATURE ?.AAAAA `[ 0NAAM DATE 2 � '_Z� <br /> 2 of 6 <br />