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Q <br /> Environmental Health Department Lu <br /> SHAWN <br /> COUN LLI <br /> APPLICATION FOR UNDERGROUND STORAGE TANK LU <br /> LU <br /> RETROFIT OR PIPING REPAIR PERMIT Q z LU <br /> a <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# CAR000192294 Project Contact&Telephone# (425)251-6222 W <br /> A <br /> C Facility Name Costco Wholesale#1031 Phone# (209)825-8200 <br /> 1 Address 2440 Daniels Street,Manteca, CA 95336 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Warehouse Manager Phone# (209)825-8200 <br /> a Contractor Name Wayne Perry Inc. Phone# 714 826-0352 <br /> T Contractor Address 8281 Commonwealth Ave. CA t is#300345 class A B C10 H <br /> A Insurer Everest National Insurance Company work Camp#CA1 0003737-181 <br /> C <br /> T ICC Technician's Name Gonzalo Gomez Expiration Date 2/12/2020 <br /> Q ICC Installer's Name Expiration Date 1/5/2020 <br /> R Gonzalo Gomez p <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T Install additional 2hp Turbine Pump on Tank 1 30,000 Gallons 87 Unleaded Gasoline 05/01/2008 <br /> A Install additional 2hp Turbine Pump on Tank 2 30,000 Gallons 87 Unleaded Gasoline 05/01/2008 <br /> N <br /> K Install additional 2hp Turbine Pump on Tank 3 30,000 Gallons 91 Premium Gasoline 05/01/2008 <br /> Install 4 additional Multi Product Dispensers <br /> Removal of existing piping to Western Dispensers <br /> Install new Vapor Recovery piping <br /> P ❑ Approved ❑ Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE NTH 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: 1 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 /> Applicant's Signatureerations Manager Date 4/15/1 q <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Alexia Inigues TITLE Senior Planner -PHONE# (425)251-6222 <br /> ADDRESS 18215 72nd Avenue South, Kent,Washington 98122 <br /> SIGNATURE DAl E <br /> 2 of 6 <br />