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SAN .,JOAQUIN Environmental Health Department <br /> - - COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN <br /> ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY <br /> DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME,ONE YEAR EXTENSION MAY BE GRANTED BY EMD UPON RECEIPT OF THIS <br /> LETTER. <br /> PROJECT CONTACT: CONTACT PHONE# <br /> Steven Nelson (425) 251-6222 <br /> FACILITY NAME: FACILITY PHONE# <br /> Costco Gasoline (Lac. No. 658) (209) 830-5340 <br /> FACILITY ADDRESS: CROSS STREET: <br /> 3250 West Grant Line Road,Tracy, CA 95377 South Lammers Road <br /> OWNER/OPERATOR: PHONE: <br /> Costco Wholesale (425) 313-8100 <br /> CONTRACTOR NAME: PHONE: <br /> Jones Covey Group, Inc. (888) 972-7581 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> 9595 Lucas Ranch Road#100, Rancho Cucamonga, CA 91730 804431 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> X YES NO T10211051 <br /> FIRE DISTRICT: PERMIT# <br /> South San Joaquin County Fire Authority Operating Permit#435 <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 5 40,000 Premium Gasoline August -15, 20211 <br /> I❑APPROVED ❑APPROVED WITH CONDITIONS ❑DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,RULES AND <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING"I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.,I SHALL NOT EMPLOY <br /> ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING "I CERTIFY THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> Appilcant's Signature <br /> Title Authorized Agent for Costco Wholesale Date July 26, 2021 <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8-hour minimum installation <br /> payment.The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name Stever: Nelson, Barghausen Consulting Engineers, Inc. Date July 26, 2021 <br /> Mailing Address 18215 72nd Avenue South, Kent, WA 98032 <br /> Signature Daytime Phone (425) 251-6222 Ext. 7372 <br /> 3 of 8 <br />