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all 1 1 $ WIN 1 %JIA UI `IULI\Vr\VUI • U JI %jr[JYVC IHIVr\ <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES Ian DAYS rnom IIIC APPnOVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> DTANK RETROFIT D PIPING REPAIRIRETROFIT O UDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site # Project contact a Telephone 1I Bruno Espinoza (909) 543 - 8904 <br /> A <br /> Facility Name Costco Gasoline 658 Phone # (888) 972-7581 <br /> L Address 3250 W Grantline Rd . , Tracy CA 95304 <br /> TCross Street <br /> Y Owner/Operator Phone # <br /> o Contractor Name Jones Covey Group , INC . Phone # (909 ) 972 -7581 <br /> N Contractor Address <br /> 7 C9595 Lucas Ranch Rd., Rancho Cucamonga, CA 91730 CA LIc # 804431 Class A , B , HAZ <br /> A Insurer Starstone National Insurance Company Work Comp # T10211051 <br /> 0ICC Techniclan's Name <br /> T Shawn Rodriguez Expiration Date 8412602 <br /> R ICC Installer's Name Shawn Rodriguez Expiration Date 8412602 <br /> Tank system work area Tank Size Chemicals Stared Current) Date UST <br /> V 0. Br piping camp, 411 loak dolader. Urc 10, tic l y Installed <br /> T 87B Tank 2 1040 , 000 87 Gasoline <br /> A <br /> N <br /> K <br /> ❑ Approved Ip Approved with Conditions I I Disapproved <br /> L <br /> A (Sun Attachment With Conditions ) <br /> N Plan Reviewers Name Uate 11 'Z j Inc <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JCLAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AMD REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL IIEALTH DEPAR7MENT OWNFR ON LKlFN SFn AlIENT'S 51G'IAIURE CERTIFIES THE FOL.LOWINO. '1 CFRTIFY 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 or CALIFORNIA.* CONTRACTOICS H(RtNG OR SLIBCONTRACTIPIG SIGNATURE CERTIFIES 711E FOLLOWING '1 CERTIFY <br /> TI IAT IN THE PERFORMANCE Or T K FOR WHICH THIS PERMIT 15 ISSUED. I SIULLL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OI" CALIFORNIA ' <br /> npplicnni's Slun;dwo Ti Jones Covdy Group - Permitting nAin 1112312022 <br /> BILLING INFORMATION : <br /> Indicate Ilia responsible party to be billed for additional EHD staff time uxpended 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 [his responsibility for the billing by signature and date below. <br /> NAME Bruno Espinoza TITLE Jones Covey Group - Permitting PHONE # 909-543- 8904 <br /> ADDRESS 9595 Lucas Ranch Rd . , Rancho Cucamonga , CA 91730 <br />