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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 IR PIPING REPAIR/RETROFIT XUDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Matt Thomas 626 -627 - 8396 <br /> � <br /> Facility Name Chevron Gas Station Phone # 707-486-8894 <br /> � <br /> Address 10878 North Highway 99 Stockton , CA 95212 <br /> Cross Street <br /> T Eight Mile Road <br /> Y Owner/Operator Muhammad Bilal Phone # 707-486- 8894 <br /> C Contractor Name CGRS , Inc. Phone # 626-627-8316 <br /> O <br /> TContractor Address 5444 Dry Creek Road CA Lic # 803616 Class A/C61 /D40/D63/HAZ <br /> R Insurer Work Com # <br /> A Pinnacol Assurance Company p WC 4632690 <br /> C <br /> T ICC Technician 's Name Richard Thomas Expiration Date 11 -18-22 <br /> Q ICC Installer's Name Richard Thomas p <br /> R Expiration Date 11 -18-22 <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 <br /> A repair 87/91 tank annular and piping <br /> N <br /> K penetrations per attached scope of work <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name ?CL" ` f v � fl Date oq t <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 �4% — �— Title Manager Date 08 / 18 /21 <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 — 8 / 18 /21 <br /> EH230038 (revised 7-26-2016) 2 <br />