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SAN JOAQUIN 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 ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Craig McLaren (805) 710-2006 <br /> A <br /> C Facility Name United Pacific #5446 Phone # (209) 943-2082 <br /> I Address 1403 Country Club Blvd , Stockton , CA 95204 <br /> L <br /> I Cross Street Pershing Ave . <br /> T <br /> Y Owner/Operator United Pacific (Apro LLC . ) Phone # (310) 612-9692 <br /> C Contractor Name Ross McLaren Phone # (805) 710-2006 <br /> 0 <br /> N Contractor Address CA Lic # 836874 ClassC61 /D40 , A, HAZ <br /> T 28030 Valcour Dr. Canyon Country, CA 91387 <br /> R <br /> A Insurer Ace American Insurance Co . Work Comp # C68652388 <br /> C <br /> T ICC Technician ' s Name Ross McLaren Expiration Date 06/26/2022 <br /> 0 <br /> R ICC Installer's Name Ross McLaren Expiration Date 04/08/2023 <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 Approved with conditions ❑ Disapproved <br /> L (S e A chment With Conditions) <br /> A N Plan Reviewers Name Date O ),61 <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." n _ <br /> Applicant's Signature �Q� Title Contractor Date 05- 15-2021 <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 Ross McLaren TITLE Contractor PHONE # 805-710-2006 <br /> ADDRESS 28003--0 Valcoourr�Dr. Canyon Country, CA 91387 <br /> SIGNATURE /CHQd �i'G(aZQ/LQ.yL DATE 05- 15-2021 <br /> 2of6 <br />