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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 /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Albert BarajaS (909) 213-5266 <br /> � Facility Name Costco 1031 Manteca Phone # (209)824-2860 <br /> 1 Address 2440 Daniels Street, Manteca CA 95336 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Costco Wholesale Phone # (209)824-2860 <br /> o Contractor Name Jones Covey Group, INC. Phone # (888)972-7581 <br /> T Contractor Address 9595 Lucas Ranch Rd., Rancho Cucamonga, CA 91730 CA Lic # 804431 Class A, B, HAZ <br /> R Insurer Insurance Company of the West Work Comp # WVA506868302 <br /> A P Y p <br /> T ICC Technician's Name Isaac Garcia Expiration Date 8192172 <br /> R ICC Installer's Name Isaac Garcia Expiration Date 8192172 <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 Tank2 87B STP Sump 30,000 Gal 87 Unleaded Gasoline <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N ` <br /> 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." <br /> /; �Q �. Assistant Environmental <br /> Applicant's Signature (/LGGf/t/1 AG�L Gay Title Date 03/21 /2025 <br /> If <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 /> Albert Bara as Assistant Environmental 909-213-5266 <br /> NAME TITLE_ Compliance PM PHONE # <br /> ADDRESS 9595 Lucas Ranch <br /> Rnd., Rancho Cucamonga, CA 91730 <br /> SIGNATURE (/LG �GvLAvlGr7 DATE 03/21 /2025 <br /> 2of6 <br />