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DocuSign Envelope ID:36BC213A-8A51-44818-3857FA4DB9A0 • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY �� � �" /� <br /> 1868 E. Hazelton Ave., Stockton, California 952 <br /> F. <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> DEC 19 2016 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMITENVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: DEPARTMENT <br /> O TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Alexia Inigues, (425)251-6222 <br /> A <br /> C Facility Name Costco Gasoline(Loc. No.038) Phone# (425)313-8100 <br /> I <br /> L Address 1630 East Hammer Lane,Stockton, CA 95210 <br /> TCross Street West Lane <br /> Y Owner/Operator Costco Wholesale Phone# (425)313-8100 <br /> o Contractor Name Jones Covey Group, Inc. Phone# <br /> NContractor Address 9595 Lucas Ranch Road,Suite 100 CA Lie# 804431 Class A,B,Haz <br /> T <br /> A Insurer Everest National Work Comp# CA10002046161 <br /> Q <br /> T ICC Technician's Name Fabian Gomez Expiration Date 5/30/2017 <br /> QICC Installer's Name William Stephen Karnes <br /> R P Expiration Date 8/6/2017 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,911esk detector,UDC 112,etc.) y Installed <br /> T 87,88,&91 Tank Vent riser base 20,000 as Gasoline Unknown <br /> A <br /> N <br /> K <br /> P ❑ Approved -'�pproved with conditions ❑ Disapproved <br /> L ( Attac ment With Conditions) <br /> A �° <br /> N Plan Reviewers NameDate <br /> / 1('f-7 <br /> APPLICANT MUST PERFORM ALL`y,VRK 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 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." Docuaigned ny: <br /> Applicant's Signatur vw id (µwTit,e Director of Gas Operations Date 12/16/2016 <br /> 831BF67C5BEB49D_. <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 Alexia Ini¢ues I{Jp,V'[w k" TITLE Project Planner PHONE# 425-313-8105 <br /> ADDRESS 18215-72nd Avenue South,Kent,WA 98032 <br /> SIGNATURE DATE /a <br /> EH230038(revised 7-26-2016) 2 <br />