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*1/ �ftw BCE9=J".99 <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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 190 DAYS FROM THE APPROVAL DATE. INDICATE PFRMIT TYPE BELOW: <br /> ®TANK RETROFIT DPIPING REPAIR/RETROF IF DUDC REPAIR/RETROFIT 000LD STARTIEVR UPGRADE <br /> F EPA Site#110038020664 Project Contact 8 Telephone#Alexia Inigues(425) 251-6222 <br /> C Facility Name Costco Gasoline(Loc. No. 38) Phone# (209) 478-2040 <br /> I Address 1616 E. Hammer Lane, Stockton <br /> L <br /> I Cross Street <br /> T <br /> Y OwnerlOperator Costco Wholesale Phone# (425) 313-8100 <br /> C Contractor Name Jones Covey Group, Inc. Phone# (951)312-4399 <br /> 0 <br /> N Contractor Address 9595 Lucas Ranch Pd.Ste 100,Rancho Cucamonga.CA 91730 CA LiC# P it 4 -1 Class A, `IA7 <br /> T <br /> A Insurer Granite State Insurance Co. Work Comp# WC009970790 <br /> C ICC Technician's Name Jason Hermosillo Expiration Date 6/22/2014 <br /> T <br /> R ICC Installer's Name Jason Hermosillo Expiration Date 12/15/2013 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i e.81 pyng sump 91�e�w edema,uoc In,Em.l Installed <br /> T TA0519781 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 proved with conditions _ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name_ - _______.__Date Z- 1— 1 <br /> APPLICANT MUST PERFORM ALL WORK N 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' CONTRAG 'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMAN�FOR I TH RMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' 77 <br /> t6wwmi 0&4. Tne Director of Real Estate Development <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per lank. 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 dale below. Attn: Ataxia Inigues <br /> NAME Barghausen Consufting Engineers, Inc. nTLe Project Planner PHONE#(425)251-6222 <br /> ADDRESS 18215.72rd Avenue South,Kent,Washington 98032 _ <br /> SIGNATURE — DATE <br /> EH230038(revised 0811111) <br /> 2 <br />