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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 ❑ PIPING REPAIR/RETROFIT ® UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # 916-991 - 1100 <br /> C Facility Name United Pacific 76 Facility #5446 Phone # <br /> 1 Address 1403 Country Club Rd . <br /> L <br /> I Cross Street N . Pershing Ave. <br /> T <br /> Y Owner/Operator United Pacific Phone # 310-323- 3992 <br /> C Contractor Name CGRS , Inc. Phone # 626-627- 8316 <br /> O <br /> N Contractor Address 5444 Dry Creek Road CA Lic # 803616 Class A/C61 /D40/D63/HAZ <br /> T <br /> R Insurer Zurich American Insurance Company Work Comp # WC 4632690 <br /> A <br /> cICC Technician's Name Richard Thomas Expiration Date s 21 -24 <br /> T <br /> R ICC Installer' s Name Richard Thomas 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 Retro Fit Kits in UDC 7-8 & test boots <br /> A in 87 turbine sump <br /> N <br /> K per scope of work <br /> P n Approved Approved with conditions iJ Disapproved <br /> L (� (See Attachment With Conditions) <br /> N Plan Reviewers Name \ " Date �- I LG E <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 /> Title Manager Date 12 / 27/22 <br /> Applicant's <br /> Si natur€ <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 <br /> Manager PHONE # 626-627-8316 <br /> ADDRESS 5444 Dry Creek Road Sacramento CA 95838 <br /> SIGNATURE _ DATE 1.2 �7 l '2. 2._ . <br /> EH230038 (revised 7-2&20i (3) 2 <br />