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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name Costco 1031 Manteca <br /> Site Address 2440 Daniels Street city Manteca state CA ZIP 95336 <br /> APN Supervisor District <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> CommentsT-2 87B Unleaded STP Sump - Demo concrete around STP Sump. Epoxy area as needed. Test repair. <br /> Fill with interstitial fluid. Backfill and resurface concrete to match existincl. <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> required <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact Property Owner ❑ Contractor ❑ Architect <br /> First Name COStGo Wholesale Last name If contractor, indicate type and license number <br /> Address City State ZIP <br /> 845 Lake Drive Issaquah WA 98027 <br /> Phone Phone Email <br /> 209-824-2860 <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner E Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Jones Covey Group, Inc. A, B, C-10, HAZ <br /> Address City State ZI P <br /> 9595 Lucas Ranch Road Rancho Cucamonga CA 91730 <br /> Phone Phone [ 'mail <br /> 909 543 8904 Cell 209 730 9185-Office bruno.espinoza@jfpetrogroup.com <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br /> form. <br /> I also certify that I have prepared this applicat0.0j,"Itwo, <br /> that the w�k o be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards, STATE and FEDERAL laws. Gli�2r2yC( 12/10/2024 �D <br /> APPLICANT'S SIGNATURE: i� DATE: <br /> ElPROPERTY/ BUSINESS OWNER ElOPERATOR/ MANAGER OTHER AUTHORIZED AGENT Permit Tech <br /> Title / <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required (���• aa�� <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, herK a2hoizlq�t�t7� <br /> release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVfkf�VMENTAL HEALTH'�C 4 <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. E q Q <br /> Accepted ey Assigned To C Tq <br /> Stu Linked FA ID►'L',►� l�G�� - � I � 7 ��R T MF <br /> Date /z f PE Fee J Record Number <br /> ElCash ❑ Check# I$confirmation # q� I�g(�, Payment <br /> Received By <br /> Rev 07/10/2024 <br />