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hl:e:UTIv9 <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. APERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHO REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. AONETIME,ONE YEAR EXTENSION MAYBE GRANTED BY EHO UPON RECEIPT OF THIS LETTER. <br /> PROJECT CONTACT: CONTACT PHONE# <br /> Ataxialnigues (425)251-6222 <br /> FACILITY NAME: FACILITY PHONE# <br /> Costco Gasoline(Loc. No.38) (209)478-2040 <br /> FACILITY ADDRESS: CROSS STREET: <br /> 1616 E.Hammer Lane,Stockton <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 It <br /> 9595 Lucas Ranch Rd, Ste 100, Rancho Cucamonga, CA 91730 804431 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> —YES NO I WC009970790 <br /> FIRE DISTRICT: PERMIT# <br /> Stockton Fire Department <br /> BOARD OF EQUALIZATION# <br /> TY(TK)HQ 44-039100 <br /> TANK 10# TANK SIZE CHEMICAL STORED __ PROPOSED INSTALL DATE____ <br /> 4 1 500 LUBRIZOL As soon as all DIa mb at"[ sued <br /> CAPPROVED —G-}APPROVED WITH CONDITIONS CDISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAMECC= z�— DATE <br /> APPLICANT MUST PERFOR LL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS. <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <br /> SIGNATURE <br /> IES THE FOLLOWING' I CERTIFY THAT IN THE I SHALL NOT EMPLOY ANY PE SN ON SUCHFARMANCE OF THE WORK FOR WHICH I <br /> MANNER AS TO BECOME SUBJECT T <br /> P <br /> PERMIT SISSUEDO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA:' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br /> CERTIFIES THE FOLLOWING "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS <br /> ISSUED,I SHALL EMPLOY .&&SONS SUBJ T W ER'S COMPENSATION LAWS OF CALIFORNIA" <br /> Appllcamrs Signature <br /> Title Director of Real Estate Development Dale <br /> Indicate the responsible party to be billed for a itional HD staff time expended beyond the 8-hour minimum installation <br /> payment.The party must acknowledge Ihls response ' or the additional billing by signature and dale below GG <br /> Name Barghausen Consulting Engineers,Inc.,Attn: Alexia Inigues Date 1 C <br /> Mailing Address 18215-72nd Avenu South,Ken[,Washington 98032 <br /> ---� 1 Daytime Phone (425)251-6222 <br /> Signature <br /> Revised H/I/11 3 <br />