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0 <br />0 <br />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 RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ©'PIPING REPAIRIRETROFIT [I UDC REPAIRIRETROFIT 19 COLD STARTIEVR UPGRADE <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC i2. etc.) <br />TLS -350 --Cold Start <br />T <br />A 91 vapor swivel adaptor <br />N <br />K <br />P LlAppr ved <br />L <br />A <br />N Plan Reviewers Name <br />Tank Size Chemicals Stared Currently Installed <br />12/3/08 <br />1121/09 <br />etproved with conditions ❑ Disapproved <br />ch ment With Conditions} ,a I / A <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 WRKER'S CERTIFY <br />THHATOIN THE PERFORM COMPENSATION <br />NCE OFLTHE WORK FOR WHICWS OF H THIS TPERMIITRIS ISSUED, I SHAL'S HIRING OR BL EMPLOY PERSOCONTRACTING INS SUBJECT TOGNATURE IW WORKERFIES THE 'S IOM ENSATION LAWSOF CALIFORNIA." <br />Title <br />CFO Date September 11, 2009 <br />Applicant's Signature <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 />Dennis Bock <br />999 LAKE DRIVE, ISSAQUAH, WA 98027 <br />TITLE 6HV.COMPLIANCEMANAGER PHONE# 42S-3f3-8iOD <br />SIGNATURE DATE September 9, 2009 <br />EH230038 (revised 02120109) <br />1 <br />Project Contact & Telephone # <br />ALEXIA INIGUES, (425) 251-6222 <br />F <br />EPA Site # <br />APhone <br />Facility Name COSTCO GASOLINE LOC. NO. 1031 <br /># 425-313-8100 <br />C <br />1 <br />Address 2440 DANIEL, MANTECA, CA 95336 <br />L <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator COS? CO WHOLESALE CORPORATION <br />Phone # 425 -3f3 -8f 00 <br />Contractor Name Central Petroleum & Maintenance <br />Prone # 925-462-4060 <br />C <br />O <br />N <br />Contractor Address 176 Wyoming Street, Pleasanton, CA 94566 CA t is # <br />491 948 Class C61 D40 <br />T <br />RInsurer <br />Work Comp # A19536158 <br />A <br />Mid Century Insurance <br />C <br />®nogg"tz/ dck.r No. 092070 a John Ensman/dck"Na.032a00 <br />ICC Technician's Name a53i733o-11# <br />Expiration Date Gragg's erswes°n 8110/2011 <br />Jnhn's espves-1511412011 <br />T <br />rs2ase,_uy <br />Gregg Geltzllicket NO.. Oa20i0 aJohn Eresmapllicket tb-002800 <br />ICC Installer's Name, <br />Expiration Date Grsggs e•pireson112512011 <br />Joan's a,<pires on 412a20„ - <br />R <br />$52056,.U1 #531,53&U, <br />Date UST <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC i2. etc.) <br />TLS -350 --Cold Start <br />T <br />A 91 vapor swivel adaptor <br />N <br />K <br />P LlAppr ved <br />L <br />A <br />N Plan Reviewers Name <br />Tank Size Chemicals Stared Currently Installed <br />12/3/08 <br />1121/09 <br />etproved with conditions ❑ Disapproved <br />ch ment With Conditions} ,a I / A <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 WRKER'S CERTIFY <br />THHATOIN THE PERFORM COMPENSATION <br />NCE OFLTHE WORK FOR WHICWS OF H THIS TPERMIITRIS ISSUED, I SHAL'S HIRING OR BL EMPLOY PERSOCONTRACTING INS SUBJECT TOGNATURE IW WORKERFIES THE 'S IOM ENSATION LAWSOF CALIFORNIA." <br />Title <br />CFO Date September 11, 2009 <br />Applicant's Signature <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 />Dennis Bock <br />999 LAKE DRIVE, ISSAQUAH, WA 98027 <br />TITLE 6HV.COMPLIANCEMANAGER PHONE# 42S-3f3-8iOD <br />SIGNATURE DATE September 9, 2009 <br />EH230038 (revised 02120109) <br />1 <br />