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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Dennie Bock <br /> A <br /> C Facility Name Coate.658 Tracy Phone# 209-834-1247 <br /> I <br /> L Address 3250 W.Grantline Rd.Tracy CA 95304 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Costen Wholesale Phone# 425-427-7653 <br /> C <br /> 0 Contractor Name Jones Covey Group,INC. Phone# 888-972-7581 <br /> N Contractor Address <br /> T 9595 Lucas Ranch Rd.Ste.90 CA LiC# 804431 Class A,B,HAZ <br /> R Insurer IDA Insurance Sendces <br /> A Work Comp# wc009970790 <br /> D ICC Technician's Name Edwin Coreas <br /> T Expiration Date 5/17/15 <br /> D ICC Installer's Name Edwin Comas <br /> R Expiration Date Ins/ts <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T RegularlTank87A 20,000 <br /> A Regular 2 Tank 87B 20,000 <br /> N <br /> K Premium Tank 20,000 <br /> Additive Tank —M mmQ' I5DO <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date ��12) <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 WHIC HIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OFC NIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE THE FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Thle Director of Service&Compliance Date 10/1/13 <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 Rick Deathriaxe TITLE Director of Service&Compliance PHONE# 888-972-7581 <br /> ADDRESS 9595 Lucas Ranch .10 - neho Cucamonga 1730 <br /> SIGNATUREjr/Z DATE 10/1/13 <br /> EH230038(revised 10/30112) <br /> 2 <br />