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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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 190 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> BANK RETROFIT 0PIPING REPAIRIRETROFIT DUDC REPAIRJRETROFIT OCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Alexia Inigues (425) 251-6222 <br /> � Facility Name Costco Gasoline(Loc. No. 658) Phone# (209) 830-5340 <br /> I <br /> L Address 3250 West Grant Line Road <br /> I Cross Street <br /> T <br /> y Owner/Operator Costco Wholesale Phone# (425) 313-8100 <br /> o Contractor Name Jones Covey Group, Inc. Phone# <br /> N Contractor Address 9595 Lueas Ranch Road.Style 100 Rancho Cucamonga.CA 91730 CA Lic# 804431 Class A, B, HAZ <br /> T <br /> R Insurer Granite State Insurance Co. Work Comp# WC009970790 <br /> A <br /> C <br /> T ICC Technician's Name Jason Hermosillo Expiration Date <br /> o ICC Installer's Name Jason Hermosillo Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (1 e.e7 pi ng� 91�aelecuv.uoc 1o.�,', Installed <br /> T TA051978l Tank Sump (1) 20,000 Regular Gasoline Existing <br /> A TA0519782 Tank Sump(2) 20,000 Regular Gasoline Existing <br /> N <br /> K TA0519783 Tank Sump (3) 20,000 Premium Gasoline Existing <br /> P Approved Approved with conditions __ Disapproved <br /> L (See ttachment With Conditions) <br /> A <br /> N Plan Reviewers Name ��iL6_,.. Date '030,12, <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 TO <br /> WORKERS COMPENSATION LAWS OF CALIFORNIA' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> AT IN THE PERFORMANCE OF THE WORK F ICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA' C <br /> �//� Director of Real Estate DevelopmerlE 0 <br /> Applicant is Signature �< Tile <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 /> Barghausen Consulting Engineers, Inc. Atte: AIexia IPlan <br /> nigues <br /> NAME TITLEProjectPHONE# <br /> (425)251-6222 <br /> ADDRESS 18215-72nd Avenue South,Kent,Washington 98032 <br /> SIGNATURE � AIZA2Qi.-1�7URVIOr DATE <br /> EH230038(revised 0811111) <br /> 2 <br />