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`*. *1111111/ BCE #14573 <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 /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW'. <br /> D TANK RETROFIT D PIPING REPAIRIRETROFIT U UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> Facility NameCOSTCO GASOLINE (LOC. NO. 1091) Phone# (425) 251-6222 <br /> I <br /> L Address 2680 REYNOLDS RANCH PARKWAY <br /> I Cross Street <br /> T <br /> y Owner/Operator COSTCO WHOLESALE Phone# 425-313-8100 <br /> C Contractor Name TO BE DETERMINED AFTER BID PROCESS Phone# <br /> 0 <br /> NContractor Address CA Lic# Class <br /> T <br /> R Insurer Work Camp# <br /> A <br /> cICC Technician's Name Expiration Date <br /> T <br /> 0 ICC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le,87 piping sump,91 leak detector.UDC 12,etc.) Installed <br /> T <br /> TA0519781 TANK SUMP (1) 30, 000 REGULAR GASOLINE Existing <br /> A TA0519782 TANK SUMP (2) 30, 000 REGULAR GASOLINE Existing <br /> IN <br /> K TA0519783 TANK SUMP (3) 30, 000 PREMIUM GASOLINE Existing <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L (S a <br /> A liment With Conditions)N <br /> Plan Reviewers Name------4A!! Date <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 AGENPS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSA710 LOWS OF CALIFORN " CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMA OF THE WORK FOR ICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Applicant's Signatu Tide Assistant Secretary Data August 9, 2012 <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 /> ATTN: Alexia Inigues <br /> NAME Barghausen Consulting Engineers, Inc. TITLE Project Planner PHONE# (425) 251-6222 <br /> ADDRESS 18215 72nd Avenue South, Kent, WA 98032 p <br /> SIGNATURE ice- 7'^■ `'� DATE <br /> EH230038(revised 0811/11) <br /> 2 <br />