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SA N YJ O A Q U IN 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 /> 1 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 /> G Contractor Name Ross McLaren Phone# (805)710-2006 <br /> 0 <br /> N Contractor Address CA Lic# 836874 <br /> T 28030 Valcour Dr.Canyon Country, CA 91387 ClassC61/D40,A, HAZ <br /> R <br /> A Insurer Ace American Insurance Co. Work Comp# C68652388 <br /> T ICC Technician's Name Ross McLaren Expiration Date 06/26/2022 <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 112,etc) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <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 AGENTS 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." Qn�_ <br /> Applicant's Signature /t9dd 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 Valcour Dr.Canyon Country,CA 91387 <br /> SIGNATURE A&d-d- DATE 05-15-2021 <br /> 2of6 <br />