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f <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 RETROFIT OR PIPING REPAIR PERMIT <br /> n- THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW' <br /> LJTANK RETROFIT []PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ®COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Alexia Dorsch - (425) 251-6222 <br /> A <br /> O FacilityName Costco Retail Fueling Facility Location No. 658 Phone# (425) 313-8100 <br /> L I Address 3250 West Grant Line Road, Tracy, CA 95377 <br /> 1 Cross Street <br /> T <br /> y Owner/Operator Costco Wholesale (Dennis Bock) Phone# (425) 313-B <br /> C Contractor Name Phone# <br /> 0 <br /> N Contractor Address <br /> r nv 4R) D CA Lic# Class <br /> R Insurer Mu U I Work Cox# <br /> A <br /> G <br /> T ICC Technician's Certification Number Explpdfion Date <br /> o <br /> R ICC Installer's Certification Number fPiration Date <br /> Tank ID# Tank Size Chemicals S ed Date UST Installed <br /> Currently/Pr iously <br /> T 1 20,000 87 octa gasoline 06/2002 <br /> A 2 20,000 87 o ane gasoline 06/2002 <br /> N <br /> K 3 20,000 9/octane gasoline 06/2002 <br /> P ❑Appro ed 6 proved with conditions ❑Disapproved <br /> L (See achment With Conditions) / <br /> A <br /> N <br /> Plan Reviewers Name Date U� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE H SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTME . OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PE IT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA" ONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PE NCE OF THE WORK FOR W THIS PERMIT IS ISSUED, SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Environmental Compliance <br /> Applicants Signature TiBe Manaqer Date V �/ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to b illed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is event than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by s' nature and date below. <br /> NAME M. Alexia I gues TITLE Project Planner PHONE# (425) 251-6222 <br /> c/o Barg a en onsu t ng Engineers, Inc. <br /> ADDRESS 18215 72nd Avenue South, ..Kent, WA 98032 <br /> SIGNATURE <br /> N. Alexia Inigues <br /> EH230038(revi d 12/31/07) <br /> 1 <br /> 10050.002.pdf <br />