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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 REPAIR/RETROFIT UDC REPAIRIRETROFIT COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />project Contact & Telephone # Isaac Anderson 209-559-1616 <br />A <br />Facility Name Costco Wholesale Manteca <br />Phone # 209-825-8200 <br />I <br />Address 2440 Daniel St. Manteca Ca, <br />L <br />T <br />Cross Street Airport Blvd. <br />Y <br />Owner/Operator CostCo Wholesale <br />Phone # 209-825-8200 <br />C <br />O <br />Contractor Name Alltech Petro, Inc <br />Phone # 209-532-7320 <br />N <br />Contractor Address P.O. Box 4208 Sonora Ca, 95327 <br />CA Lic# 623541 Class p, <br />T <br />R <br />Insurer Frenkel Environmental <br />Work Comp # 1940433-10 <br />A <br />C <br />T <br />ICC Technician's Name Chad White 8011608 -UT <br />Expiration Date 06-09-2012 <br />R <br />ICC Installer's Name Chad White 8011608-LJT <br />Expiration Date 06-09-2012 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i. e- 87 piping sump, 91 leak deleclo , DDC 1l2, etc.) <br />T <br />91 Leak Detector <br />30K <br />91 <br />2008 <br />A <br />N <br />K <br />P Approved Approved with conditions Disapproved <br />L (See Attachment With Conditions) <br />A / <br />N Plan Reviewers Name _tea __ 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 <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WO FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA " <br />Ap—n...,r....,,,4.£ e�,.nfi �— Title Technician _Date 08-19-2010 <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 acknowledge <br />this responsibility for the billing by signature and date below - <br />Isaac Anderson <br />O. Box 4208 �5pnora Ca, 95370 <br />SIGNA <br />EH230038 <br />TITLE Technician PHONE # 209-532-7320 <br />2 <br />TE08-25-2010 <br />