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'1111i *mo' <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> TIIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BEI 0: <br /> I110rANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site#110037381543 Project Contact&Telephone#Alexia Inigues(425) 251-6222 <br /> A <br /> c Facility Name Costco Gasoline(Loc. No. 103 1) Phone# (209) 825-8200 <br /> I <br /> L Address 2440 Daniels Street, Manteca <br /> TCross Street <br /> Y Owner/Operator Costco Wholesale Phone# (425) 313-8100 <br /> c Contractor Name Jones Covey Group, Inc. Phone# (951) 312-4399 <br /> N Contractor Address 9595 LUoa$Ranch Road.Suite 100 Rancho Cucamonga,CA 91730 CA Lic# 804431 Class A, 8, HAZ <br /> T <br /> A Insurer Granite State Insurance Co. Work Comp# WC009970790 <br /> DICC Technicians Name <br /> T ' Jason Hermosillo Expiration Dale <br /> R ICC Installer's Name Jason Hermosillo Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> h 0.97 PIPn9W p 91 Ueak Eeteacr. JDC 1.4,etc.) Installed <br /> T TA0519781 Tank Sump (1) 30,000 Regular Gasoline Existing <br /> A TA0519782 Tank Sump(2) 30,000 Regular Gasoline Existing <br /> N <br /> K TA0519783 Tank Sump (3) 30,000 Premium Gasoline Existing <br /> P Approved Approved with conditions __ Disapproved <br /> LX(See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 41 4p�/ILA w Date 030-7 <br /> a <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: 1 CERTIFY THAT IN <br /> THE PFRFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKERS COMPENSATION LAWS OF CALIFORNIA' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'i CERTIFY <br /> THAT IN THE PERFOR OF TH W K WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S OMPENSATION LAWS <br /> Of CALIFORNIA' / <br /> �1 Director of Real Estate Development <br /> { ature Talc Date <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 /> Barghausen Consulting Engineers, Inc. Atte. PProjectxia Planne� (425)251-6222 <br /> NAME TITLE 1 PHONE# <br /> ADDRESS 16215-72nd Avenue South,Kent,Washington 98032 <br /> SIGNATURE ������ ATEA701 r TJ 2. <br /> EH230038(revised 08/1/111 <br /> 2 <br />