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SAN.J O A Q I N <br /> Environmental Health Department <br /> COl-) NT <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 /> � Facility Name United Pacific#5446 Phone#310-808-6812 <br /> 1 Address 1403 Country Club Drive Stockton, CA <br /> TCross Street North Pershing Drive <br /> Y owner/OperatorBoyett Petroleum - Monica Farhat Phone#209-549-5612 <br /> C Contractor NameCGRS, Inc. Phone#g16-991-1100 <br /> 0 <br /> N Contractor Address 5444 Dry Creek Road Sacramento, CA 95838 CA Lic# 803616 A/HAZ <br /> T Class <br /> R A InsurerPinnacol Assurance Work Comp#4029480 <br /> T ICC Technician's Name Richard Thomas Expiration Date 9/21/26 <br /> R ICC Installer's Name RorhardExpiration Date9/21/26 <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 <br /> N <br /> K <br /> P ❑ Approved X Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name - Date 5/15/2025 <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 11-7-2024 <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 Compliance Services Manager PHONE#626-627-8316 <br /> ADDRESS 5444 Dry (--rePk Road Sacramento, CA 95838 <br /> SIGNATURE ' DATE 1 1-7-2024 <br /> 2 of 6 <br />