Laserfiche WebLink
0 9 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <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# <br /> C Facility Name United Pacific 76 Facility#5447 Phone# 209-478-1522 <br /> 1 Address 1469 East Hammer Lane <br /> L <br /> I Cross Street West Lane <br /> T <br /> Y Owner/Operator United Pacific Phone# 310-323-3992 <br /> C Contractor Name CGRS, Inc. Phone# 626-627-8316 <br /> 0 <br /> TContractor Address 5444 Dry Creek Road CA Lic# 803616 Class wcsliDaoiDs3iHAz <br /> R Insurer Work Comp# WC 4632690 <br /> A Zurich American Insurance Company <br /> C <br /> r ICC Technician's Name Richard rhomas Expiration Date 11-18-18 <br /> ° Richard Thomas ICC Installer's Name <br /> R Expiration Date 11-18-18 <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 UDC's 1-2,3-4,5-6,7-8,&9-10 <br /> A 91 fill&vapor bucket <br /> N <br /> K tank annular sensors <br /> 01 <br /> P ElApproved Approved with conditions ®EP �- roH.vre�' �'TH <br /> L (See Attachment With Conditions) �� <br /> A �`1\�_,,.,, � ^^ <br /> N Plan Reviewers Name G 1�/�l�lk �p��: Date �� d <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 Title Manager Date 8-3-18 <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 CGRS,Inc.Matt Thomas TITLE Manager PHONE# 626-627-8316 <br /> ADDRESS 5444 Dry Creek Road Sacramento CA 95838 <br /> SIGNATURE //.r, DATE 8-3-18 <br /> EH230038(revised 7-26-2016) 2 <br />