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w � <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN <br /> ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME,ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER, <br /> PROJECT CONTACT: CONTACT PHONE# <br /> Alexia Inigues (425)251-6222 <br /> FACILITY NAME: FACILITY PHONE# <br /> Costco Gasoline (Loc. No. 658) (209) 830-5340 <br /> FACILITY ADDRESS: CROSS STREET: - <br /> 3250 West Grant Line Road <br /> OW NERIOPERATOR: PHONE: <br /> Costco Wholesale (425) 313-8100 <br /> CONTRACTOR NAME: PHONE: <br /> Jones Covey Group, Inc. (951)312-4399 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> 9595 Lucas Ranch Rd, Ste 100 Rancho Cucamonga, CA 91730 804431 A, B, HAZ <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> YES NO WC009970790 <br /> FIRE DISTRICT: PERMIT# <br /> BOARD OF EQUALIZATION# <br /> TY (TK) HQ 44-039100 <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 4 1,500 LUBRIZOL As soon as all permits are issued <br /> [APPROVED APPROVED WITH CONDITIONS COISAPPROVED <br /> (see attachments) n <br /> PLAN REVIEWER'S NAME DATE o� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCOREMINCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <br /> SIGNATURE CERTIFIES THE FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br /> 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 <br /> CERTIFIES THE FOLLOWING 'i CERTIFY THAT IN TH /.PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS <br /> ISSUED,I SHALL EMPLOY PERSON SUBJ C RKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> i <br /> Applicant's Signature <br /> Title Director of Real Estate Development <br /> Indicate the responsible party to be billed for additi I EHD staff time expended beyond the 8-hour minimum installation <br /> payment.The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name Barghausen Consulting Engineers, Inc.,Attn: Alexia Inigues Date <br /> Mailing Address 18215-72nd Avenue South, Kent,Washington 98032 _ <br /> Signature�� Q. Daytime Phone (425)251-6222 <br /> Revised 8iI/I I 3 <br />