Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave . , Stockton , California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 /> D TANK RETROFIT O PIPING REPAIRIRETROFIT XI UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # 714-975-4257 <br /> � Facility Name Costco Wholesale #1091 CERS ID : 10146151 Phone # 800-562-6210 <br /> I <br /> L Address 2680 Reynolds Ranch Parkway, Lodi CA 95240 <br /> TCross Street E Harney Ln <br /> Y Owner/Operator Costco Wholesale Corporation Phone # 425-313-8100 <br /> C Contractor Name Jones Covey Group, Inc. Phone # 888-972-7581 <br /> 0 <br /> N Contractor Address 9595 Lucas Ranch Road #100 Rancho Cucamonga, CA 91730 CA LIC # 804431 Class A, B HAZ <br /> T <br /> R <br /> A Insurer Everest National Insurance Company Work Comp # CA1002046171 <br /> 0ICC Technician's Name Fabian Gomez ICC: 8289138 Expiration Date 5/20/19 <br /> T <br /> R ICC Installer's Name Fabian Gomez Expiration Date 5/20/19 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le. 97 piping sump, 91 leak detector, UDC 112, etc,) Installed <br /> T Tank 1 -87A 30,000 Gallon Unleaded Gasoline <br /> A Tank 2-87B 30,000 Gallon Unleaded Gasoline <br /> N <br /> K Tank 3-91 30,000 Gallon Premium Gasoline <br /> P ❑ Approved * Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name azz!7�7Z L� Date 0 L11 -01114P <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." <br /> Applicant's Signature ��, Title Project Support Date 3-26-18 <br /> BILLING INFORMATION : <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. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Rob Sills TITLE Project Support PHONE # 714-975-4257 <br /> ADDRESS 9595 Lucas Ranch Road #100 Rancho Cucamonga, CA 91730 <br /> SIGNATURE DATE 3-26-18 <br /> EH230038 (revised 7-26-2016) 2 <br />