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SQ N JOAQUIN 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 0 PIPING REPAIR/RETROFIT 11 UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> I F EPA Site # CAR000227926 Project Contact & Telephone # 425 - 251 - 6222 <br /> A Facility Name Costco Gasoline ( Loc . No . 38 ) Phone # 209 - 478 - 2040 <br /> Address 1630 East Hammer Lane , Stockton , CA 95210 <br /> L <br /> Cross Street West Lane Frontage Road <br /> T <br /> Y Owner/Operator Costco Wholesale Phone # 425 -313 -8100 <br /> C Contractor Name Phone # <br /> o _ <br /> T Contractor Address _ Class <br /> R Insurer NOT APPLICABLE -- <br /> A cork Comp; # <br /> TICC Technician's Name Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detvdor, UPC 112, etc. ) Installed <br /> T Gasoline Additive 1500 Gasoline Additive Mixture 5/31 /2013 <br /> A <br /> IN _..._ <br /> K <br /> P ❑ Approved s Approved with conditions _i Disapproved <br /> L ( See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name �� � � <br /> 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. " <br /> Applicant's Signature Title Authorized Agent Date <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 M . Alexia Inigues TITLE Authorized Agent PHONE # 425 - 251 - 6222 <br /> ADDRESS 18215 72nd Avenue South , Kent , WA 98032 <br /> SIGNATURE. P DATE <br /> 2 of 6 <br />