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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 ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#626-627-8316 <br /> C Facility Name Boyett Petroleum #113 Phone#209-549-5612 <br /> 1 Address 420 W Kettleman Lane Lodi CA 95240 <br /> L <br /> TCross Street Hutchins St <br /> Y owner/OperatorBoyett Petroleum - Monica Farhat Phone#209-549-5612 <br /> C Contractor Name CGRS, Inc. Phone#916-991-1100 <br /> O <br /> N Contractor Address 5444 Dry Creek Road Sacramento, CA 95838 CA Lic# 803616 ClaSSA/HAZ <br /> T <br /> R A InsurerPinnacol Assurance Work Comp#4029480 <br /> T ]CC Technician's Name Richard Thomas Expiration Date9/21/25 <br /> R ICC Installer's Name Expiration Date9/21/26 <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 Install 208 sensor in diesel sump diesel <br /> A Install 323 senor in e85 sump e85 <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name_���� M� Date to l'o ` ` (0 -'r <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 3-1 1-2025 <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 Matt Thomas TITLE Compliance Services Manager PHONE#626-627-8316 <br /> ADDRESS 5444 Dry Creek Road Sacramento, CA 95838 <br /> SIGNATURE /iZj2Cr� DATE 1-16-2025 <br /> 2 of 6 <br />