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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 ONE TIME,ONE YEAR EXTENSION MAY BE 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. 1091) (209) 366-7300 <br /> FACILITY ADDRESS: CROSS STREET: <br /> 2680 REYNOLDS RANCH PARKWAY, LODI, CA 95240 E . HARNEY LANE <br /> OWNERIOPERATOR: PHONE: <br /> COSTCO WHOLESALE 425-313-8100 <br /> CONTRACTOR NAME: PHONE: <br /> JONES COVEY GROUP, INC. (909) 972-5781 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> 9595 LUCAS RANCH ROAD, SUITE 100 <br /> RANCHO CUCAMONGA, CA 91730 804431 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> X YES NO I W0009970790 <br /> FIRE DISTRICT: PERMIT# <br /> CITY OF LODI <br /> BOARD OF EQUALIZATION# <br /> TY (TK) HQ 44-039100 <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 4 1, 500 LUBRIZOL as soon as all permits <br /> D APPROVED WIPPROVED WITH CONDITIONS ❑DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE I '✓ / <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN 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 FOLLOWIN CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS <br /> ISSUED, I SHALL EMPLOY PtFjSONS SUR7,71F�CT TO KER' COMPENSATION LAWS OF CALIFORNIA." <br /> Applicant's Signature C <br /> Title_4S'SiS'fWNT - teFT1g1e_%._ Date i0/7- /Z0/3 <br /> Indicate the responsible party to be billed for additional 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 <br /> Mailing Address 18215 72nd Avenue South, Kent, WA 98032 <br /> Signature _ Daytime Phone (425) 251-6222 <br /> Revised 8/1/11 3 <br />