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ENVIRONMENTAL HEALTH DEPARTMENT <br /> f � y <br /> SAN JOAQUIN COUNTY At <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 JAN 3 2019 <br /> Telephone : (209) 468 -3420 Fax : (209) 468 -3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ' �'� ' E Vita <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 # <br /> � Facility Name Stockton 76 Phone # 408-593- 3190 <br /> i Address8606 Thornton Road <br /> L <br /> TCross Street Davis Road <br /> Y Owner/Operator Amba Rai Phone # 408- 593-3190 <br /> C Contractor Name CGRS , Inc . Phone # 916- 991 - 11oo <br /> O <br /> N Contractor Address 5444 Dry Creek Road Sacramento , CA 95838 CA Lic # 803616 Class A/C61 /D40JD63/HAz <br /> T <br /> A Insurer Zuirch American Insurance Company Work Comp # WC 4632690 <br /> C <br /> T ICC Technician 's Name Richard Thomas Expiration Date <br /> Q <br /> R ICC Installer's Name Richard Thomas Expiration Date <br /> ' <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T 87 , 89 , & 91 spill buckets and overfill valves 10K/10K/ 10k gasoline <br /> A see attached plan set <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> i <br /> N Plan Reviewers Name Date t <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> j 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." ),r <br /> Applicant's Signaturei"eTitle Manager- CGRS , Inc. Date 1 -31 - 19 <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 Matt Thomas- CGRS , Inc . TITLE Manager PHONE # 626-627-8316 <br /> ADDRESS 5444 Dry Creek Road Sacramento , CA 95838 <br /> SIGNATURE / /ZBI'N-Cl-d DATE 1 -31 - 19 <br /> K EH230038 (revised 7-26-2016) 2 <br /> l <br /> i <br /> t <br />