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06/20/2002 09:39 FAX 425 251 8782 BARGRAUSEN Z002/002 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMLNTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS 1S ONLY VALID FOR THE CALENDAR YEAR IM WHICH IT HAS BEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REDUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR TEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS_ <br /> EPA SITE # PROJECF CONTACT & TELEPHONE # 4 <br /> F FACILITY NAME COSTCO GASOLINE IAC. f pi35PHONE s (425) 313-8100 <br /> A - ---__ <br /> C ADDRESS Tracy Marketplace on Grantline Road, Tracy, CA <br /> I <br /> L CROSS STREET Tracy Marketplace / Granlline Read <br /> I - <br /> T OWNER/OPERATOR PHONE # <br /> Y Costco Wholesale Corp- (425) 313-8100 <br /> C CONTRACTOR NAME W A Ci QA,b i NC; PHONE # -10.7_ 2.g2-q2 <br /> 0 <br /> N CONTRACTOR ADDRESS`7�} <br /> i cLAss <br /> I jntyp+ Roo A 5 - 8AZ. <br /> R <br /> HAZARDOUS WASTE CERTIFIED YES— ( NO (ON "A" l{ r�,Sc WORK.C;OMP.#'r—01 Uf71-�0000455 ak <br /> A �y(riCl <br /> C FIRE DISTRICT PERMIT # <br /> 7 <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> in�nertir��irnir�rnrinni <br /> { TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 1 39 —� — 20,000 87 octane 0'1 DALE <br /> - Oct�n� 02Q02 <br /> A 39 <br /> N 39- —ZO. 00 92 ortnne 0317007 <br /> K 39- <br /> 39- <br /> 39- <br /> nrrmmmm <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAT! REVIEWERS NAME DATE <br /> nrrlrrnirrinrr111 r [111111111111111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOVIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFOR14ANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PARSON IN SUCH A MANNER AS TO BECCME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUSCOIITRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CER7IFY THAT IN THE PERFORMANCE OF THE WORK F IS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS sMJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIF NIA-" <br /> APPLICANT'S SIGNATURE: - <br /> ♦ TITL£ +�, DATE <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimus installation <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date below- <br /> Nam Costco Wholesale Ca <br /> Mailing Address 999 Lake Drive, Issaquah, WA. 98027 <br /> Day Phone Number (425) 313-8100 / <br /> Signature �TReq's <br /> C2�I �� � r C�C <br /> DateEH 23 008 (Rev 12/ ay 5, 1994) <br /> 4 <br />