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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECOVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 MAR 0 7 20% <br /> �IVIRONMEN1AL HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TAN PERMIPSERVICES <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ©TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# CAR000116947 Project Contact&Telephone# Mike Ellis(951)675-7233 <br /> Facility Name Costco 0658 Phone# (209) 834-1247 <br /> Address 3250 W. Grantline Rd <br /> L -- — - - <br /> 1 Cross Street Lammers Rd. <br /> T __-_... <br /> Y Owner/Operator Costco Whosale Inc. Phone# 425-427-7653 <br /> C Contractor Name Belshire Environmental Services, Inc. Phone# (949)460-5200 <br /> 0 <br /> N Contractor Address CA Lic# Class <br /> .I. _ 25971 Towne Canine Dr.,Foothill Ranch,CA 92610 808313 AIHaa <br /> R <br /> n Insurer Great Divide Insurance Co. Work Camp it WCA1547285-13 <br /> G <br /> r ICC Technician's Name Saul Gonzales Expiration Date 9125/2017 <br /> ._ <br /> R ICC Installer's Name Saul Gonzales Expiration Date 6/15/2017 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC W,OK) Installed <br /> T UDC 1-2 (3) 20,000 Gasoline <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A I <br /> N Plan Reviewers Name_._ Date 4 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CO TY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS 0 <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENS AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY TF <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 SUBJE- <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING., "I CE <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJE=CT TO WORKER'S COMPENSATION <br /> OF CALIFORNIA." F) <br /> �+� -�- Title Project Manager nate 03/18/2016 $1 a.'YL <br /> Applicant's Signature �} <br /> Qy vL.Q <br /> BILLING INFORMATION: + ill <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. properly owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Mike Ellis TITLE Project Manager PHONE# (951) 675-7233 <br /> ADDRESS 25971 Towne Centre Dr., Foothill Ranch, CA 92610 <br /> SIGNATUREMr kI, �ffi.d. DATE 0212212016 <br /> E1-1230038(revised 07-17-2014) <br /> 2 <br />