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,I~ <br /> DocuSign Envelope IDI:F75FD7A6-E33A-4165-9F1 E-9C6FD5CCCC30 <br /> SAN :J O A Q U I N En ironmental Healthq tment <br /> COUNTY <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 /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# CAR000192294 Project Contact&Telephone# (425)251-6222 <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 /> >I r <br /> �intractorAd <br /> rldrr;; <br /> - -� To Be Submitted under separate cover <br /> 1rsu.er �Nork �.cmp r <br /> - ----- -- — --- -- - once bid has been selected <br /> ICC I eche an',Name ,'cx, Dat�, <br /> 1 ;r s N2it1r I Expiration (Date <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 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 ZApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A r , <br /> N Plan Reviewers Name V �G Date <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." DocuSigned by: <br /> Applicant's Signature 61M Title Director of Real Estate Development Date 3/18/2019 <br /> 82785FCF9858480.. <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 Q� <br /> SIGNATURE - DATE <br /> 2of6 <br />