Laserfiche WebLink
ENVIRONM.NTAL HEALTH DL-'ARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue, Third Floor, 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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT XPIPING REPAIR/RETROFIT ❑UDC REPAIRJRETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name Costco Wholesale Phone#209-830-5343 <br /> 1L Address 3250 Grantline Road, Tracy, CA 95376 <br /> TCross Street <br /> Y Owner/Operator Phone# <br /> C Contractor Name Central Petroleum Maintenance Phone# 925-4624060 <br /> 0 <br /> T Contractor Address 176 Wyoming Street, Pleasanton, CA 94566 CA Lic# 491948 Class C61-1340 <br /> R Insurer Farmers Insurance Work Comp# A1953-61-58 <br /> A <br /> C ICC Technician's Certification Number Expiration Date <br /> T <br /> 0 <br /> R ICC Installers Certification Number 5252156-U1 Expiration Date 08/22/07 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> 87A 12,000 87 octane gasoline <br /> A <br /> N <br /> K <br /> P ❑Approved Approved with conditions []Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name l�/' `�"l Date h 3 a b <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 THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title Date <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 Kathleen Henshaw TITLE CFO PHONE# 925-4624060 <br /> ADDRESS 176 Wyoming Street, �Pleasanton, CA 94566 <br /> SIGNATURE DlJO�X .!/.Gi'bCL`�vr-✓ <br /> EH230038(revised 8/8/06) <br /> 1 <br />