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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN <br /> ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONETIME,ONE YEAR EXTENSION MAYBE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. <br /> PROJECT CONTACT: CONTACT PHONE# <br /> Alexia Inigues (425)251-6222 <br /> FACILITY NAME: FACILITY PHONE# <br /> Costco Gasoline (Loc. No.1031) (209) 825-8200 <br /> FACILITY ADDRESS: CROSS STREET: --_m.�..._�....�._ <br /> 2440 Daniels Street <br /> OWNERIOPERATOR: PHONE: <br /> Costco Wholesale (425)313-8100 <br /> CONTRACTOR NAME: PHONE: <br /> Jones Covey Group, Inc. (951)312-4399 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> 9595 Lucas Ranch Road, Suite 100 804431 A, B, HAZ <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COM-P-# <br /> YES NO WC009970790 <br /> FIRE DISTRICT: PERMIT# <br /> BOARD OF EQUALIZATION# <br /> TY (TK) HO 44-039100 <br /> TANK ID # TANK SIZE CHEMICAL STORED _ ___ PROPOSED INSTALL DATE <br /> q 1�b0 LUBRIZOL As soon as all permits are issued <br /> &APPROVED APPROVED WITHCONDITIONS &DISAPPROVED <br /> (see attachments) �T_` <br /> PLAN REVIEWER'S NAME DATE U3v7 CI <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN J57AQUIN COUNTY ORDINANCES,STATE LAWS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <br /> SIGNATURE CERTIFIES THE FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br /> 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 <br /> CERTIFIES THE FOLLOWING "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS <br /> ISSUED, I SHALL EMPLOY P RSONS SUBJE T TO WORKER'S COMPENSATION LAWS OF CALIFORNIA,- <br /> Applicant's Signature <br /> Title Director of Real Estate Development <br /> Indicate the responsible party to be billed for a 'b al EHD staff time expended beyond the 8-hour minimum installation <br /> payment.The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name Barghausen Consulting Engineers,Inc_, Attn: Alexia Inigues_ Date__- 1 ��[� <br /> Mailing Address 18215- 72nd Avenue South, Kent, Washington 98032 <br /> Signature Daytime Phone (425)251-6222 <br /> Revised 8/11/11 3 <br />