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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> APPLICATION FOR UNDERGROUNDA STORA EH TA KISION INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-FHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. 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 # PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME COSTCO GASOLINE LOC. #()�3r) PHONE # (425) 313-$100 <br /> A <br /> C ADDRESS Tracy Marketplace on Grantline Road, Tracy, CA <br /> 1 <br /> L CROSS STREET Tracy Marketplace / Grantline Road <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y Costco Wholesale Corp. (425) 313-8100 <br /> C CONTRACTOR NAME to be determined PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC # <br /> T CLASS <br /> R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T - <br /> 0 BOARD OF EQUALIZATION # <br /> R _-- <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- 1 20,000 87 octane 03 DATE 2002oCta _ <br /> T 39 <br /> n <br /> A 39 ,000 92 octane 0312009 <br /> N 39- - <br /> K 39- <br /> 39- <br /> 39- <br /> I <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> IN <br /> (SEE ATTACHMENT WITH CONDITIONS) <br /> PLAN REVIEWERS NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FO l5 PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSAIION LAWS OF !CALIFD-NIA.11APPLICANT'S SIGNATURE �` TITLE �?" �L DATE`'Z�l� z�?J <br /> Indicate the responsible party to be billed for additions! PNS-EHD staff time expended beyond the 8 hour minimum fnstatiation <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> I� Name Costco Wholesale Corp. <br /> i <br /> Mailing Address 999 Lake Drive, Issaquah, WA. 98027 <br /> Day Phone Number (425) 313-8100 <br /> Signature �� r Date �C�/ 17 <br /> EH 23 008 (Rev 12/ 5, Un Reg's May 5, 1994) <br /> 4 <br /> 1 <br />