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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 /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW- <br /> JTANK RETROFIT DPIPING REPAIRIRETROFIT E1UDC REPAIRIRETROFIT XCOLD START/EVR UPGRADE <br /> F EPA Site Project Contact&Telephone# Alexia Dorsch - (425) 251-6222 <br /> A <br /> G Facility Name Costco Retail Fueling Facility Location No. 658 Phone# (425) 313-8100 <br /> IL Address 3250 West Grant Line Road, Tracy, CA 95377 <br /> I Cross Street <br /> T <br /> Y owner/Operator Costco Wholesale (Dennis Bock) Phone# (425) 313-8100 <br /> c Contractor Name Phone# <br /> 0 <br /> T Contractor Address D CA Lic# Class <br /> R Li Insurer Work Comp# <br /> A <br /> D ICC Technician's Certification Number Expiration Date <br /> T <br /> o <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> 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 OApproved Approved with conditions ODisapproved <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 AGENTS 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 '1 CERTIFY <br /> THAT IN THE PE CE OF THE WORK FOR WHIC THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' <br /> Environmental Compl'_ance n <br /> Applicants Signature Tifie Manaqer Date r� <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 /> NAME M. Alexia Inigues TITLE Project Planner PHONE# (425) 251-6222 <br /> c/o Barghausen Consulting ngineers, nc. <br /> ADDRESS 18215 — 72nd Avenue South„Kentt, WA 980322 <br /> SIGNATURE ` V-------/� <br /> M. Alexia Inigues <br /> EH230038(revised 12/31/07) <br /> 1 <br /> 10050.002.ptlf <br />