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SA N JOAQUIN Environmental Health Department <br /> - - COU N T Y - <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 # Project Contact & Telephone # Bruno Espinoza ( 909 ) 543 - 8904 <br /> � <br /> Facility Name Costco Gasoline 658 Phone # ( $ $ $ ) 972 - 7581 <br /> � Address 3250 W Grantline Rd . , Tracy CA 95304 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Phone # <br /> C Contractor Name Jones Covey Group , INC . Phone # ( 909 ) 972 - 7581 <br /> T Contractor Address 8595 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 /> T ICC Technician ' s Name Shawn Rodriguez Expiration Date 8412602 <br /> R ICC Installer' s Name Shawn Rodriguez Expiration Date 8412602 <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 87B Tank 2 10 ' - 40 , 000 87 Gasoline <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 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 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 Bruno Espinoza TITLE PHONE # 909 - 543 - 8904 <br /> ADDRESS 9595 Lucas Ranch Rd . , Rancho Cucamonga , CA 91730 <br /> SIGNATURE / —� DATE 10/27/2022 <br /> 2of6 <br />