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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY - <br /> EIVEs <br /> t fi# <br /> a _ r <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 ! � . r ,, <br /> Telephone : ( 209 ) 468 - 3420 Fax : ( 209 ) 468 - 3433 AUG 2 2019 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTALHEALTF9 <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: a 9- AP 3TMEN <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/ RETROFIT ® UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> A Facility Name United Pacific 76 Facility Phone # <br /> C v Y - #5447 <br /> � Address 1469 E . Hammer Lane <br /> I Cross Street <br /> T West Ln . <br /> Y Owner/Operator United Pacific Phone # 310- 323 - 3992 <br /> C Contractor Name CGRS , Inc . Phone # 626 -627-8316 <br /> 0 <br /> TContractor Address 5444 Dry Creek Road CA Lic # 803616 Class A/C61 /D40/D63/HAZ <br /> R Insurer Work Com # <br /> A Zurich American Insurance Company p WC 4632690 <br /> C ICC Technician ' s Name Richard Thomas Expiration Date 11 - 18-20 <br /> T <br /> 0 <br /> R ICC Installer' s Name Richard Thomas Expiration Date 11 - 18-20 <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 Saw cut, demo, and install new OPW Edge Doublewall <br /> A per attached <br /> N <br /> K scope of work <br /> P Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A I <br /> N Plan Reviewers Name �Au \ S 0 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 Title Manager Date 08 / 12/ 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 CGRS , Inc. Matt Thomas TITLE Manager PHONE # 626-627-8316 <br /> ADDRESS 5444 Dry Creek Road Sacramento CA 95838 <br /> SIGNATURE DATE 08 / 12/ 19 <br /> EH230038 ( revised 7-26-2016) 2 <br />