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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 # 626-627-8316 <br /> A <br /> Facility Name J & L Market Phone # 209-451 -7520 <br /> L <br /> Address 8125 South EI Dorado Street, French Camp , 95446 <br /> I Cross Street W, Mathews Rd <br /> T <br /> Y Owner/Operator Vanessa Cortez Phone # 209-451 -7520 <br /> C Contractor Name Phone # 626-627-8316 <br /> 0 CGRS Inc <br /> TContractor Address 5444 Dry Creek Rd . CA Lic # 803616 CIBSS A/C61 /D40 D83/HAZ <br /> R Insurer Work Comp # <br /> A PFS Insurance Grou4029480 ( attached ) <br /> ICC Technician ' s NameRangelExpiration Date <br /> T Richard Thomas + Leo p 10/7/22 + 02/ 13/22 <br /> o ICC Installer's Name Expiration Date 10/7/22 + 02/ 13/22 <br /> R Richard Thomas + Leo Rangel P� <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 Per attached scope of work <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions ) <br /> A o ', <br /> N Plan Reviewers Name Date <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 626-627-8316 Date 04/ 14/22 <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 Matt Thomas TITLE Manager PHONE # 626-627-8316 <br /> ADDRESS 5444 Dry Creek Road Sacramento CA 95838 <br /> SIGNATURE / DATE 04/ 14/22 <br /> 2of6 <br />