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SANJOAQUIN Environmental Health Department <br /> Cr- <br /> ) UNI Y <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS <br /> SUBSTANCES STORAGE TANK( S) EXPIRES 180 DAYS FROM THE APPROVAL DATE . DO NOT WRITE IN ANY SHADED AREAS , <br /> INDICATE PERMIT TYPE : <br /> ❑ REMOVAL ® TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # PROJECT CONTACT Steven Nelson PHONE# 425 251 - 6222 <br /> FACILITY NAME Costco Gasoline Loc . No . 658 PHONE # 209 830 - 5340 <br /> ADDRESS 3250 West Grant Line Road Tracy , CA 95377 <br /> CROSS STREET South Lammers Road <br /> OWNER OPERATOR Costco Wholesale PHONE It 425 251 - 6222 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Jones Covey Groug , Inc . PHONE # 888 972 - 7581 <br /> CONTRACTOR ADDRESS 9595 Lucas Ranch Rd . # 100 , Rancho Cucamon a , CA 91730 CA LIC # 804431 CLASS A B HAZ <br /> INSURER Berkshire Hathaway Homestate Insurance WORKER COMP# JOWC320551 <br /> FIRE DISTRICT South San Joaquin County Fire Authority PERMIT # F22 - 009 <br /> LABORATORY NAME N/A COUNTY IPHONE # <br /> SAMPLING FIRM N /A PHONE # <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39 - 0005182880515627 20 , 000 Unleaded Gasoline 7/ 11 /2002 <br /> 39 - 0005182880515628 20 , 000 Unleaded Gasoline 7/ 11 /2002 <br /> 39 - 0005182880515629 20 , 000 Unleaded Gasoline 7/ 11 /2002 <br /> 39 - 0005182880520535 1 500 LUBRIZOL additive 5/ 15/2013 <br /> 39 - <br /> 39 - <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS , FEDERAL LAWS, AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING : "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> Authorized Agent for <br /> APPLICANT ' S SIGNATURE i� TITLE Costco Wholesale DATE 5/5/2022 <br /> ❑ APPROVED APPROVED WITH CONDITION ( S ) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME_ DAT E ~ � 2 � <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK . <br /> CONDITIONS . <br /> 3 of 10 <br />