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ENVIRONMeNTAL HEALTH DE-eARTMENT <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 RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT PCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Alexia Dorsch - (425) 251-6222 <br /> A <br /> C Facility Name Costco Retail Fueling Facility Location No. 658 Phone# (425) 313-8100 <br /> � Address 3250 West Grant Line Road, Tracy, CA 95377 <br /> T <br /> Cross Street <br /> Y Owner/Operator Costco Wholesale (Dennis Bock) Phone# (425) 313-8100 <br /> pContractor Name Phone# <br /> N Contractor Address <br /> T DU CA Lic# Class <br /> R <br /> nsurWork Comp# <br /> Q er <br /> T ICC Technician's Certific ' n umber Expiration Date <br /> RICC Installer's Certification Number <br /> Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T 1 20, 000 87 octane gasoline 06/2002 <br /> A 2 20,000 B7 octane gasoline 06/2002 <br /> N <br /> K 3 20,000 91 octane gasoline 06/2002 <br /> P ❑Approved ❑Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 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 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 PERFO E OF THE WORK FOR THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OFCALIFORNIA.° C <br /> X 1 Environmental Compliance 7 ,^� <br /> Applicants Signature J Title Manager Date (/W <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. Environmental <br /> NAME Dennis Bock TITLE Compliance Manager PHONE# (425) 313-8700 <br /> ADDRESS 999 Lake <br /> /Drive, Issaquah, WA 98027 <br /> SIGNATURE X '� "'✓1 <br /> EH230038(revised 12/31/07) <br /> 1 10050.002.pdf <br />