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SANJOAQUIN 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 /> X TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT [J COLD START/EVR UPGRADE <br /> F EPA Site # CAR000227926 Project Contact & Telephone # Steven Nelson (425) 251 - 6222 <br /> C Facility Name Costco Gasoline ( Loc . No . 038) Phone # (209 ) 478- 2040 <br /> I Address 1630 East Hammer Lane , Stockton , CA 95210 <br /> L <br /> TCross Street West Lane Frontage Road <br /> Y Owner/Operator Costco Wholesale Phone # (425 ) 313-8100 <br /> D Contractor Name Gettler- Ryan Inc . Phone # (925 ) 551 -7444 <br /> 0 <br /> N Contractor Address 6805 Sierra Ct , Suite G , Dublin , CA 94568 CA Lic # 220793 Class C-61 / D40 <br /> T <br /> R <br /> A Insurer Zurich American Insurance Company Work Comp # WC090463402 <br /> T ICC Technician 's Name Matthew Campbell Expiration Date 3/ 13/2023 <br /> o <br /> R ICC Installer's Name Same as above Expiration Date Same as above <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (1,e. 87 piping sump, 91 leak detector, IIDC 112, etc.) Installed <br /> T Tank 1 Fill Sump 30 , 000 87 Unleaded Gasoline 3/1 /2004 <br /> A Tank 2 Fill Sump 30, 000 87 Unleaded Gasoline 3/1 /2004 <br /> N <br /> K Tank 3 Fill Sump 30 , 000 91 Unleaded Premium 3/1 /2004 <br /> P El Approved #pproved with conditions ❑ Disapproved <br /> L ment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date qg ozZ <br /> APPLICANT MUST PERFORM ALL WORK I CCORDANCE 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 LTrue Manager / Authorized Agent Dale October 29 , 2021 <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 Steven Nelson TITLE Project Coordinator PHONE # (425) 251 - 6222 <br /> ADDRESS 18215 72nd Avenue South Kent , WA 98032 <br /> SIGNATURE c DATE October 29 , 2021 <br /> 2of6 <br />