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ENVIRONMENTAL HEALTH DEPARTpg�tIVED <br />SAN JOAQUIN COUNTY MAR D 1 2016 <br />1868 E. Hazelton Ave., Stockton, California 95205NV`IIONiIVTAL <br />Telephone: (209) 468-3420 Fax- (209) 468-3433 sa�sITU r,�r3APTAA--NI-r <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 REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # Project Contact A Telephone # Megan Mitchell 209-461-6337 <br />C <br />Facility Name Costco 1031 <br />Phone 209-824-2$60 <br />I <br />L <br />Address 2440 Daniels St Manteca CA 95336 <br />I <br />T <br />Cross Street <br />Y <br />Owner/Oporator Dave Zizzo Phone # 208-824-2860 <br />0 <br />Contractor Name Elite V C Ctor Phone # 209-461-6337 <br />_ <br />T <br />Contractor Address 2535 Wipwarn Dr Stackt Class A-HAZ <br />A <br />insurer Midwest Employers Casualt Com an <br />nq; <br /># BNUWC0133392 <br />C <br />T <br />ICC Technician's Name <br />ate <br />RICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(Le, 87 p�ping surra, 91 leak aetecwr, uDc irz, slc.I <br />Tank Size <br />Chemicals Stored Current) Y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved ® Approved with conditions ❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />1` <br />N <br />Plan Reviewers Name L - Date -3 <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 AGLNT'S SIGNATURE CERTIFIES T14E FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON TN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR SJBCONTRACTING 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 />CALIFORNIA." <br />lOF <br />ApplicantsSignature Title Office Assistant Date 2129116 <br />105 <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. if <br />the party designated below is different than the permit applicant, e.g, property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME Megan Mitchell TITLE Office Assistant PHONE # 209-461-6337 <br />2595 Wigwam Dr Stockton Ca 95205 <br />SIGNATURE rlLlg;� & DATE 2129116 <br />EH23W38 (revised 12-11-15) <br />