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uocuolgn Cnveiape iu: lt,anua44ru <br /> L HEALTH D�ARTMEN a <br /> ENVIRONII�NTA , �� Iy <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave. Stockton, California 9E IVSD <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> DEC 27211t6 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMEWRONMENTAL�HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELC�I EPARTMEI VT <br /> ❑TANK RETROFIT C1 PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Alexia Inigues <br /> APhane# (425) 313-8100 <br /> C Facility Name Costco Gasoline (Loc No. 658) <br /> I Address3250 West Grantline Road Tracy, California 95377 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Costco Wholesale Phone# (425) 313-8100 <br /> C Contractor Name Jones Covey Group, Inc. Phone# <br /> 0 <br /> N Contractor Address 9595 Lucas Ranch Road Suite 100 <br /> T CA Lic# 804431 Class A,B,Haz <br /> R insurer Everett National Work Comp# CA100020461161 <br /> A <br /> T ICC Technician's Name Fabian Gomez Expiration Date 5/30/2017 <br /> Q <br /> R ICC Installer's Name William Stephen Karras Expiration Date 08/06/2017 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 teak deteclor,UDC 112,etc.) Installed <br /> 87, 86, & 91 Tank Vent [riser Base 20, 000 Each Gasoline Unknown <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved /Tachment <br /> pproved with conditions Ll Disapproved <br /> L See With Conditions) <br /> A <br /> N Plan Reviewers Na a Date f I <br /> APPLICANT MUST PERFORM ALL W RK 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." Docusignedby: Director of Gas <br /> �Wl . title Operations Date 12/21/2016 <br /> Applicant's Signature barstAAi — <br /> B31SF67C5BEBOD <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 Inigues TITLE Project Planner PHONE# (425) 313-8105 <br /> ADDRESS 18215 72nd Avenue South Kent, WA 98032 <br /> SIGNATURE rpm-� '""` DATE ! <br /> EH230038(revised 7-26-2016) 2 <br />