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i <br /> SANJOAQUIN Environmental Health Department <br /> C U U [% \I I Y <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 n UDC REPAIR/RETROFIT -I COLD START/EVR UPGRADE <br /> F EPA Site # CAR000192294 Project Contact & Telephone # 425 -251 -6222 <br /> C Facility Name Costco Gasoline ( Loc . No . 1091 ) Phone # 209 - 478- 2040 <br /> 1 Address 2680 Reynolds Ranch Parkway , Lodi , CA 95240 <br /> Cross Street Rocky Lane <br /> T — -- — -- - <br /> Y owner/operator Costco Wholesale Phone # 425 - 313 - 8100 <br /> C Contractor Name _ Phone # <br /> O <br /> TContractor AddressClass <br /> R NOT APPLIGABL' <br /> A Insurer , , � Co, lj # <br /> TICC Technician 's Name Expiration Date <br /> RICC Installer' s Name Expiration Date <br /> Tank system work area Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 112, etc.) Tank Size Chemicals Stored Currently Installed <br /> Gasoline Additive 1 , 500 Gasoline Additive Mixture 2/5/2013 <br /> A <br /> N - -- - - <br /> K <br /> P F] Approved i Approved with conditions U Disapproved <br /> L ( See A achment With Conditions ) <br /> A <br /> N Plan Reviewers Name j v 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 AGENTS 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 DATE K131 / © J <br /> 2of6 <br />