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DocuSign Envelope ID:57852BDB-FD2B-4170-B5C8-435307C98954 <br /> 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 /> IXTANK RETROFIT lX PIPING REPAIR/RETROFIT N 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. 658) Phone# (209) 830-5340 <br /> � Address 3250 West Grant Line Road, Tracy, CA 95377 <br /> 1 Cross Street South Lammers Road <br /> T <br /> Y Owner/Operator Costco Wholesale Phone# (425) 251-6222 <br /> C Contractor Name Jones Covey Group, Inc. Phone# (888) 972-7581 <br /> O <br /> N Contractor Address 9595 Lucas Ranch Road#100, CA Lic# 804431 Class A, B, HAZ <br /> T Rancho Cucamoncla.CA 91730 <br /> A Insurer StarStone National Insurance Company Work Comp# T10211051 <br /> T ICC Technician's Name Ovidiu Valimareanu Expiration Date 01/15/2023 <br /> Q ICC Installer's Name Expiration Date 01/12/2023 <br /> R Ovidiu Valimareanu p� <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T TANK#1 87 UNL. REGULAR 20K UNLEADED GASOLINE 7/11/2002 <br /> A TANK#2 87 UNL. REGULAR 20K UNLEADED GASOLINE 7/11/2002 <br /> N <br /> K TANK#3 91 UNL. PREMIUM(CONVERT TO 87) 20K UNLEADED GASOLINE 7/11/2002 <br /> TANK#4 GASOLINE ADDITIVE 1.5K LUBRIZOL 5/15/2013 <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See 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 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." Authorized Agent for <br /> DocuSignetl by: <br /> Applicant's Signature Title Costco Wholesale Date December 3, 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 Barghausen Consulting Engineers, Inc., 18215 72nd Avenue South, Kent, WA 98032 <br /> SIGNATURE DATE December 3, 2021 <br /> 2of6 <br />