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SANJOAQUIN Environmental Health Department <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 X UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # 425 -251 - 6222 <br /> � Facility Name Costco Gas Loc . No 1091 Phone # 209- 366 - 7332 <br /> Address 2680 Reynolds Ranch Parkway , Lodi , CA 5240 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Costco Wholesale Phone # 209-366 -7332 <br /> o Contractor Name Elite IV Contractors Phone # 209 -461 - 6337 <br /> T Contractor Address 2535 Wigwam Drive , Stockton , CA 95205 CA Lic # 1001331 Class A - HAZ <br /> A Insurer MID West Employers Casualty Company Work Comp # BNUWC0133392 <br /> ° <br /> T ICC Technician 's Name Hank Moore Expiration Date 9/25/ 19 <br /> ° ICC Installer's Name Hank Moore p' 9/25/ 19 <br /> R Expiration Date <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 Ilk <br /> A <br /> N <br /> K <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 ACCOMANCE 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 /> j 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 Signature Title Senior Planner Date June 13 , 2019 <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 Barghausen Consulting Engineers Inc. TITLE Authorized Agent PHONE # 425 - 251 - 6222 <br /> ADDRESS 18215 72nd Avenue South Kent , WA 98032 <br /> SIGNATURE DATE June 13 , 2019 <br /> 2of6 <br />