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Q <br /> CGRS <br /> SOLUTIONS DELIVERED <br /> GENERAL CONTRACTOR STATEMENT <br /> Effective 05/26/15,the State Water Resources Control Board requires that the signed general <br /> contractor's statement be received from all general contractors prior to formal notification of final <br /> ELD testing (NO EXCEPTIONS). <br /> By signing below,the general contractor acknowledges that: <br /> "No further ground penetrating work,including beautification requirements,atop or immediately <br /> adjacent to,the UST system are needed or will be performed after ELD testing is performed." <br /> General Contractor Information <br /> Company Name/CA Contractor License#: B&T Service Station Contractors <br /> Contact: Les Henderson <br /> Address: 630 S. Frontage Rd., Nipomo, CA 93444 <br /> Telephone/Email: 805-431-8839/les@btssc.com <br /> Site Information <br /> Site Name: Safeway#55 <br /> Address: 19533 S. Mountain House Pkwy, Mountain House,CA 95381 <br /> Telephone: unknown <br /> County: San Joaquin <br /> CUPA Contact: San Joaquin County Environmental Health <br /> CUPA Email: ust@sjgov.org <br /> Testing Company Information <br /> Name: CGRS, Inc. <br /> Technician Assigned/License#: Sergio L. Nunez/#06-1727 <br /> Signature <br /> General Contractor's Signature: <br /> Name(print): FABIO SILVA <br /> Title: PROJECT ASSISTANT Date of Signature: 06/01/2022 <br /> 5444 Dry Creek Rd. Sacramento,CA 95838 T916-991-1100 F 916-991-1177 www.cgrs.com <br />