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r; CGRS <br /> `..~ SOLUTIONS DELIVERED - <br /> GENERAL CO ACT0[t STATEMEW <br /> Effective 05/26/15,the State Water Resources Control Board requires tfiat the signed general <br /> contractor's statement be received from all general contractors prior to formal notification of final <br /> ELD testing (NO EXCEPTIONS). <br /> By signing below,the general contractor acknowledges that: <br /> "No further ground penetrating work,including beautification requirements,atop or immediately <br /> adjacent to,the UST system are needed or willbe performed after ELD testing is performed." <br /> General Contractor Information <br /> Company Name/CA Contractor License#: Wayne Perry, Inc. <br /> Contact: Gonzalo Gomez <br /> Address: 8281 Commonwealth Ave., Buena Park, 90621 <br /> Telephone/Email: 951-855-4629/ggomez@wpinc.com <br /> Site Information <br /> Site Name: Costco <br /> Address: 2680 Reynolds Ranch Pkwy,Lodi,CA 95240 <br /> Telephone: unknown <br /> County: San Joaquin <br /> CUPA Email: ust@sjgov.org <br /> Testing Company Information <br /> Name: CGRS, Inc. <br /> Technician Assigned/License#: Adam Montejano/#1775 <br /> Signature <br /> General Contractor's Signature: `I <br /> Name(print): Nv%A%a V�,t41 49 <br /> Title: S!n�ev-• Kk4-1 A Date of Signature: 0 !Lt 3 oZ le <br /> 54"Dry Creek Rd. Sacramento,CA 95838 T 916-991-1100 F 916.991.1177 www.cgrs.com <br />