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SAN , JOAQUIN 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 N UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # 5 6 2 — 2 3 1 — 8 2 2 1 <br /> C Facility Name Costco Facility # 0038 Phone # 209 - 478 - 2040 <br /> I <br /> L Address 1616 E Hammer Ln , Stockton CA 95210 <br /> TCross Street West Ln <br /> Y Owner/Operator Costco Wholesale Phone # <br /> C Contractor Name Wayne Perry Inc Phone # <br /> 0 <br /> N Contractor Address 8281 Commonwealth ave CALic # 300345 Class B HAZ <br /> T <br /> R <br /> A Insurer Everest Premier Work Comp # CA10003737221 <br /> T ICC Technician 's Name Nick Harvey Expiration Date 12 / 03 / 2022 <br /> R ICC Installer's Name Nick Harvey Expiration Date 08 / 28 / 2023 <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 <br /> UDC 1 / 2 and 11 / 12 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L 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 1S 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 PERFORMANCEOF T WORK FO HICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." /� P1 <br /> Applicant's Signature Title � aa'rt*-(� rl" l,�y�-, LfC' Dale 4t Z � 2 ✓V (� l� <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 Alan Evans TITLE Project Manager PHONE # 562 - 231 - 8221 <br /> ADDRESS 8281 Commonwealth ave , Buena Park CA 90621 <br /> SIGNATURE DATE <br /> 8 / 29 / 2022 <br /> 2of6 <br />