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F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />`c <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />O <br />R <br />0 <br />0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Maim Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468--14-33 <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 REPAIRIRETROFIT UDC REPAIRIRETROFIT COLD STARTIEVR UPGRADE <br />EPA Site # <br />Facility Name Costco Wholesale Manteca <br />Address 2440 Daniel St. Manteca Ca, <br />cross Street Airport Blvd. <br />Owner/Operator Costco Wholesale <br />Project Contact & Telephone # Isaac Anderson 209-559-1616 <br />Phone # 209-825-8200 <br />contractor Name Alltech Petro, Inc <br />Contractor Address P O. Box 4208 Sonora Ca, 95327 <br />In! rer Frenkel Environmental <br />ICC Technidari s Name Isaac Anderson 8005930 -UT <br />ICC Installers Name Isaac Anderson 8005930 -UT <br />Tank system work arlea <br />06 1"'OPM scarp 91 leak deter UDC IR..,) Tank Size <br />T UDC 7-8. Replaced L23 dispensor <br />A pan secondary containment sensor. <br />N <br />K <br />Phone # 209-825-8200 <br />Phone # 209-532-7320 <br />CA Lic # 6 2 3 5 41 Class A <br />work Comp# 1940433_10 <br />Expiration Date 06-09-2012 <br />Expiration Date 06-09-2012 <br />Chemicals Stored Currently Date UST <br />Installed <br />P Approved Approved with corr3tioing Pp <br />L ed <br />A See Attachment vvo Cor> %Nw) <br />N <br />Plan Reviewers Name 1 /�,.� pate <br />APPWANTT MIDST PERFORM ALL WORK IN ACCORDVJCE 7MTH SAN JOAQUIN COLNTY ORDINANCES. STATE LAWS. ANI) RULES AND REGULATK)NS OF SAN <br />JOAMIN COUNTY, EWRONMENTAL HEALTH bEPARTMENT. OWMER OR LICENSER AGENTS SIGNATURE CERTIFIES THE FOLLOMpW[ -1 CERTIFY THAT IN <br />7HETO PERFORMANCE OF THE WORK FOR WWH THIS PERMIT IS ISSUED. i SHALL NOT EMPLOY AW PERSON IN SUCH A MAIMIE R AS TO BECOME S116JECT <br />MYORKERS COMPENSATION LAWS OF CALIFORNIA - CONTRACTOR'S HS%ING OR SUBCONTR/ICnMG SIGUATURE CERT* -WS THE FOLLOMANC, 7 CEFrIIFY <br />THAT IN TFIF PERFORMANCE OF THE WO FOR W)9CH TFNS PERMIT IS ISSUED_ I SFLAi. L FWLQY p SUBJECT TO "�9iORICER S EItSATgN LAWS <br />OF CAIJFORMIA' <br />ADGlemIrs Signe T,�Technlclan no, 08-18-2411 <br />17 BILLING IIVFORMATI©IV: <br />Indicate the responsible party to be billed for additional EFID staff time expended beyond permit paymerd coverage per <br />tank. II the party designated below is different than tt�e permit applicant. e.g_ property owner, the party must acknowledge <br />this responsibility for the billing by signature and date below. <br />NAME Isaac Anderson TITLE Technician F'HONiE li 209-532-7320 <br />ADoREssP 0. Box 4208 Spnora Ca, 95370 <br />SIGNATURE HATE 08-18-2011 <br />EIi23DD38 freti 122110 <br />2 <br />