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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 /> XTANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Steven Nelson 425 251 - 6222 <br /> C Facility Name Costco Gasoline ( Loc . No . 1091 ) Phone # ( 209) 366 -7300 <br /> I <br /> L Address 2680 Reynolds Ranch Parkway , Lodi , CA 95240 <br /> 1 Cross Street Rocky Lane <br /> T <br /> Y Owner/Operator Costco Wholesale Phone # (425 ) 313 -8100 <br /> C Contractor Name Gettler-Ryan Inc . Phone # ( 925 ) 551 -7444 <br /> O <br /> N <br /> T Contractor Address 6805 Sierra Ct , Suite G , Dublin , CA 94568 CA Lic # 220793 Class C- 61 / D40 <br /> R <br /> A Insurer Zurich American Insurance Company Work Comp # WC090463402 <br /> C <br /> T ICC Technician 's Name Matthew Campbell Expiration Date 3/ 13/2023 <br /> i <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 /> (Le. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T Tank 1 Fill Sump 30 , 000 87 Unleaded Gasoline 12/2/2010 <br /> A Tank 2 Fill Sump 30 , 000 87 Unleaded Gasoline 12/2/2010 <br /> N <br /> K Tank 3 Fill Sump 30 , 000 91 Premium Gasoline 12/2/2010 <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( e At chment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date 311 6Z Q � cl <br /> — <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�"*L+ nager / Authorized Agent Date November 5 , 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 -- DATE November 5, 2021 <br /> 2of6 <br />