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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 SEP 14 2018 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL <br /> RETROFIT OR PIPING REPAIR PERMIT HEALTH DFORAPITME NT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> DTANK RETROFIT 0 PIPING REPAIR/RETROFIT EIUDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name United Pacific 76 Facility#5447 Phone# 209-478-1522 <br /> 1 Address <br /> L 1469 East Hammer Lane <br /> I Cross Street West Lane <br /> T <br /> Y Owner/Operator United Pacific Phone# 310-323-3992 <br /> c Contractor Name CGIRS, Inc. Phone# 626-627-" <br /> 0 <br /> T <br /> N Contractor Address 5444 Dry reeoaC <br /> Ck Rd CA # 803616 lassA/C61/D40/D63/HAZ <br /> Z <br /> R <br /> A Insurer ZurichAmerican Insurance Company Work Comp WC 4632690 <br /> C <br /> T ICC Technician's Name Richard Thomas Expiratxl'n Date 11-18-18 <br /> 0 <br /> EO <br /> R ICC Installer's Name Richard Thomas (ration Date 11-18-18 <br /> Tank system work area Tank Size Chemic/aStored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T U DC'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 /> Z <br /> P El Approved El/pproved with conditions El Disapproved <br /> L (See ttaclhment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE H SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PER IT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." C NTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR W//HICTHIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Tide Manager Date 8-3-18 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be b* ed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> I <br /> diff <br /> the party designated below is dii rent than the permit applicant, e.g. property owner, the party must acknowledge this <br /> I <br /> responsibility for the billing by sign/re and date below. <br /> NAME CGRS,Inc.Matt Thomas TITLE Manager PHONE# 626-627-8316 <br /> ADDRESS 5444 Dry Creek Road/acramento CA 95838 <br /> SIGNATURE -DATE 8-3-18 <br /> EH230038(revised 7-26-2016) 2 <br />