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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMITTYPE BELOW: <br />n TANK RETROFIT C PIPING REPAIRIRETROFIT 13 UDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br />F <br />A <br />EPA Site # <br />I Project Contact 8 Telephone # Matt Thomas 626-627-8396 <br />C <br />Facility Name United Pacific 76 Facility #5447 Phone # <br />� <br />Address 1469 E. Hammer Lane <br />T <br />Cross Street West Ln. <br />Y <br />Owner/Operator United Pacific Phone # 310-323-3992 <br />cContractor <br />o <br />NContractor <br />Name CGRS, Inc. Phone # 626-627-8316 <br />T <br />R <br />Address 5444 Dry Creek Road CA Lic # 8Q3616 Class Arc61rD40ro63/Haz <br />A <br />Insurer <br />IPinnaml Assurance Company Work Comp # WC 4632690 <br />T <br />o <br />ICC Technician's Name RichardThomas Expiration Date 19 ZyZ <br />R ICC Installer's Name Richard Thomas Expiration Date 101-7 12-2-- <br />=ZTank <br />Tanksystem work area Date UST <br />0 87 p,grxg SUMP, 91 leak date=. UDC 12, etc) Tank Size Chemicals Stored Currently <br />Installed <br />T <br />A repair LIDC's per attached <br />N <br />K scope of work <br />P _ Approved Approved with conditions ❑ Disapproved <br />L <br />A (See Attachment With Conditions) <br />N Plan Reviewers Name Date 9-15-2U2-1 <br />PLJCANT 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 THES 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 1S ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA' <br />Applicant's Signaturl�Y�,Tige Manager _GG -,e5 Date 08/14/21 <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 />CGRS, Inc. Matt Thames TITLE Manager PHONE # 626.827-8316 <br />5444 Dry Creak Road Sacramento CA 08838 <br />_ SIGNA <br />EH230038 (revised 7-28-2018) <br />8!34/21 <br />