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SANJOAQUIN Environmental Health Department <br /> --- COUNTY -- <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 IX UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Matt Thomas 626-627- 8316 <br /> A <br /> C Facility Name Save on Fuel Phone # 510-393-6916 <br /> I <br /> L Address 420 West Yosemite - Manteca , CA 95337 <br /> I Cross Street Jessie Ave . <br /> T <br /> Y Owner/Operator Kash Ban Phone # 510-393-6916 <br /> c Contractor Name CGRS , Inc. Phone # 916-991 - 1100 <br /> 0 <br /> N Contractor Address 5444 Dry Creek Road Sacramento , CA 95838 CA Lic # 803616 Class A/C61 /C40/D63/HAZ <br /> R <br /> A Insurer Pinnacol Assurance Co Work Comp # 4029480 <br /> C ICC Technician 's Name Expiration Date <br /> T Richard Thomas p � 10/7/2022 <br /> 0 ICC Installer's Name Expiration Date <br /> R Richard Thomas P 10/7/2022 <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 UDC # 1 /2 SB989 Secondary Piping Repair regular unleaded gasoline <br /> A <br /> N <br /> K <br /> P ❑ Approved . Z Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A VC , <br /> 1 —I ) 0 �7 <br /> NPlan Reviewers Name 1 v 'ro Date 01 u <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 6/8/2021 <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 CGRS , Inc. - Matt Thomas TITLE Compliance Services Manager PHONE # 916-991 -1100 <br /> ADDRESS 5444 Dry Creek Road Sacramento, CA 95838 <br /> SIGNATURE �4 - �— DATE 6/8/2021 <br /> 2of6 <br />