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ENVIRONMCNTAL HEALTH DEOAR7 TWFD <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 SEP 1 1 2008 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 ENVIRONMENT HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPIhd,4E0Xi06-E�RMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ®COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Alexia Dorsch - (425) 251-6222 <br /> � Facility Name Costco Retail Fueling Facility Location No. 658 Phone# (425) 313-8100 <br /> 1 L Address 3250 West Grant Line Road, Tracy, CA 95377 <br /> TCross Street <br /> Y Owner/Operator Costco Wholesale (Contact: Dennis Sock) Phone# (425) 313-8100 <br /> Q Contra ctor Name pacific Northern Environmental Phone# (800) 533-2867 <br /> 0 <br /> N Contractor Address 1081 Columbia Blvd. , Longview, W <br /> T A 98632 CA LIC# 787580 Class A, B, HAZ <br /> R Insurer Zurich American Insurance Company Work Comp# WC272221111 <br /> A <br /> C <br /> T ICC Technician's Certification Number see attached Expiration Date <br /> oR ICC Installer's Certification Number See attached Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> 1 20,000 87 octane gasoline 06/2002 <br /> T <br /> A 2 20,000 87 octane gasoline 06/2002 <br /> N <br /> K 3 20,000 91 octane gasoline 06/2002 <br /> P ❑Appro d Approved with conditions ❑Disapproved <br /> L ( e ttachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date v( <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 AGENT'S 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 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Environmental Compliance C_ <br /> Applicants Signature Title Manager Date d <br /> en is Bock 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 /> Environmental <br /> NAME Dennis Bock TITLECompliance Manager PHONE# (425) 313-8700 <br /> ADDRESS 999 Lake Drive, Issaquah, WA 98027 <br /> SIGNATURE X <br /> EH230038(revised 31/07) <br /> 1 10050.002.pdf <br />