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DocuSign Envelope ID:2F173BE3-D39C-47D3-A993-65B9F76377E9 <br /> SANJOAQUIN Environmental Health Department <br /> COUNTY— <br /> APPLICATION <br /> OUNTYAPPLICATION 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# CAR000227926 Project Contact&Telephone# 425-656-1064 <br /> A <br /> C Facility Name Costco Gasoline(Loc.38) Phone# 209-478-2040 <br /> 1 Address 1630 E Hammer LN,Stockton,CA 95210 <br /> L <br /> I Cross Street Prontaoe Road <br /> T <br /> Y Owner/Operator Tim Hurlocker Phone# 425-818-3100 <br /> C Contractor Name Wayne Perry, Inc.ATT:Tom Faludy Phone# 714-826-0352 <br /> O <br /> T Contractor Address 8281 Commonwealth Avenue,Buena Park,CA 90621 CA Lic# 300345 Class A,021,0 10, C57 <br /> R <br /> A Insurer Everest National Insurance Co. Work Comp# CA10003737211 <br /> T ICC Technician's Name See Attached List Expiration Date <br /> T p See Attached List <br /> R ICC Installer's Name See Attached List Expiration Date See Attached List <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 20,000 Gasoline(regular) 2004 <br /> A 20,000 Gasoline(regular) 2004 <br /> N <br /> K 20,000 Gasoline(premium) 2004 <br /> 1,500 Gasoline Additive(Lubrizol) 2013 <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 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 Authorized Agent of Owner Date <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 M.Alexia Iniques TITLE Authorized Agent of Owner PHONE# 425-251-6222 <br /> ADDRESS c/o Barghausen Consulting Engineers, Inc. 18215 72nd Ave.S.Kent,WA 98032 <br /> DocuSigned by: <br /> SIGNATURE FE DATE 2/9/2021 <br /> 1342DDM7813OF48D... <br /> 2 of 6 <br />