Laserfiche WebLink
. �; EIVED <br /> SAN JOAQUIN Environmental Health [ORRrW Tnt2Q23 <br /> COUNTY <br /> i=. NVIRONMENTAL HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TANK PERMIT/ SERVICES <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 REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Matt Thomas 626-627-8316 <br /> A <br /> C Facility Name United Pacific #5447 Phone # 310- 323-3992 <br /> I <br /> L Address 1469 East Hammer Lane Stockton <br /> I Cross Street West Lane <br /> T <br /> Y Owner/Operator Tom Robins Phone # 310-323-3992 <br /> C Contractor Name CGRS , Inc . Phone # <br /> 0 916-991 - 1100 <br /> N Contractor Address 5444 Dry Creek Road Sacramento CA 9583 CA Lic # 803616 Class A/ HAZ <br /> R Insurer Work Com <br /> A Pinnacol Assurance Co P429480 <br /> C ICC Technician ' s Name Expiration Date <br /> T Richard Thomas p 9 -21 -24 <br /> R ICC Installer's Name Expiration Date 9-20-24 <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 install Bravo B2000 retro kits in <br /> A dispensers 3-4 & 7- 8 per attached <br /> N <br /> K SOW & Puns <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( ee tachment With Conditions) <br /> A <br /> N Plan Reviewers Name 1 Date I <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 Compliance Services Manager Date 3- 1 -2023 <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 TITLOomplinace Services Manager PHONEfj�26 -627- 8316 <br /> ADDRESS 54,,4,/4 Dry Creek Road Sacramento CA 95838 <br /> SIGNATURE 7`X2 -/ /LbAP2 DATE 3 - 1 -23 <br /> 2 of 6 <br />