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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME,ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. PROJECT CONTACT: Harley Mattson, Barghausen CONTACT PHONE# (425) 251-6222 Consultin En iners Inc. FACILITY NAME: Costco Gasoline Loc. No. 38 FACILITY PHONE# (425) 478-2040 FACILITY ADDRESS: CROSS STREET: 1616 East Hammer Lane, Stockton West Lane OWNER/OPERATOR Costco Wholesale PHONE: (425) 313-6100 CONTRACTOR NAME: TBD PHONE: CONTRACTOR ADDRESS: CA LICENSE# CLASS: FiRF DISTRICT City of Stockton TANK ID# TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALL DATE 1 20,000 87 Octane Gasoline 9/1/02 2 20,000 87 Octane Gasoline 9/1/02 3 20,000 92 Octane Gasoline 911/02 APPROVED APPROVED WITH CONDITION DISAPPROVED (see attachmeIth conditions) PLAN REVIEWER'S NAME DATE D APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WOH THIS PERMIT IS ISSUE ALL EMP Y PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA" APPLICANT'S SIGNATURE? TITLE DATE�2�7 Z Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name Costco Wholesale Corvoration Mailing Address 999 Lake Drive, Issaquah, WA 98027 Day Phone, ,mber� (425) 313-6100 Signature I ml� Date_ V r J Z EH 23 008(R v 3/15/02)