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BCE#10050 <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: Install PLLD <br /> ® 87 Line Split <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone# alexia Inigues - (425) 656-7430 <br /> A <br /> C Facility Name Costco Retail Fueling Facility Location No. 658 Phone# (425) 313-8100 <br /> I <br /> L Address 3250 West Grantline Road, Tracy, California 95377 <br /> 1 Cross Street West 11th Street <br /> T <br /> Y Owner/Operator Costco Wholesale (Dennis Bock) Phone# (425) 313-8100 <br /> C Contractor Name WSR & Sons, Inc. Phone# (951) 906-3023 <br /> O <br /> NContractor Address 34455 Sunlight Drive CA Lic# 888712 Class A,C10 <br /> T <br /> A Insurer NorGuard Insurance Company Work Comp# WSWC905525 <br /> T ICC Technician's Name will be sent prior to permit issuance Expiration Date <br /> QICC Installers Name will be sent <br /> R prior to permit issuance Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leek detector.UDC 112,etc.) Installed <br /> 87 leak detector 20,000 87 Octane Gasoline 06/2002 <br /> T <br /> A 87 leak detector 20,000 87 Octane Gasoline 06/2002 <br /> N <br /> K 91 Leak Detector 20,000 91 Octane Gasoline 06/2002 <br /> P ❑ Appro ed ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> AIr�� <br /> N Plan Reviewers Name Date l�f I C; / <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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Environmental <br /> Applicant's Signature Title COmplienCe Manager Date 04/08/09 <br /> Dennis Bock 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 /> Environmental <br /> NAME Dennis Bock TITLE Compliance Manager PHONE# (425) 313-8700 <br /> ADDRESS 999 Lake Drive, Issaquah WA 98027 /�, <br /> SIGNATURE 1 DATE —/ <br /> EH230038(revised 02/20/09) <br /> 1 <br /> 10050.004-pdf.doc <br />