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ENVIRONMENTAL HEALTH DEPARTMENT SCE#,D,PB <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 /> 0 TANK RETROFIT 91 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Alexia Inigues-(425)251-6222 <br /> A <br /> Facility Name Costco Gasoline Phone#(425) 313-8100 <br /> L Address 1616 East Hammer Lane <br /> T <br /> Cross street West Lane <br /> Y Owner/Operator Costco Wholesale Phone# (425)313-8100 <br /> C <br /> 0 Contractor Name Wayne Perry Ina Phone# <br /> T Contractor Address 8281 Commonwealth Ave,Baena Park,CA 906210 CA LIC# 300345 Class see attached <br /> RInsurer PATRIOT RISK AND INSURANCE SERVICES <br /> A Work Comp# BB1101086 <br /> DICC Technician's Name RYAN NULTNER <br /> T Expiration Date 9/08/2012 <br /> QICC Installer's Name RYAN HULTNER <br /> R Expiration Date 5/13/2011 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 PION sump,91 bak dela r,IIM 112,elc.) Installed <br /> T 87, 87 & 91 Tank Vent riser base 20,000 ea Gasoline Unknown <br /> A <br /> N <br /> K <br /> I ' <br /> P ApprovedApproved with conditions Disapproved <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Nam Date 1'j <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 <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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" �_ -- L <br /> Applicant's Signature 75x -- Tille Env. Compliance Manager Dare (425) 313-8100 <br /> — — -- -- BILLING-INFORMATIONS— ---.--- --- <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 /> Environmental <br /> NAME Dennis Bock rrrLE Compliance Manager PHONE# (425)313-8100 <br /> ADDRESS 999 Lake Drive Issaquah WA 98027� / <br /> SIGNATURE � 'H'ro [�7T� DATE 11/12/2010 <br /> EH230038(revised 07/22/10) <br /> i <br /> 2 <br />