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' <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 /> PROJECTCONTACT: CONTACT PHONE# <br /> Dennis Bock (425)313-8100 <br /> FACILITY NAME: FACILITY PHONE# <br /> Costco Gasoline (425)313-8100 <br /> FACILITY ADDRESS: CROSS STREET: <br /> 322 East Harney Lane, Lodi, CA Reynolds Ranch Parkway <br /> ODYN EIVOPERATOR: PHONE: <br /> Costco Wholesale (425)313-8100 <br /> CONTRACTOR NANIE: PHONE: <br /> TBD <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> IIA7_ARDOCS WASTE CERTIFICATE: WORKERS CONIP# <br /> YES NO <br /> FIRE DISTRICT: PERMIT# <br /> City of Lodi <br /> BOARD OF EQUALIZATION # <br /> TY CPK/ Fifes 44-039106 <br /> TANK ID# TANK SIZE CHENHCAL STORED PROPOSED INSTALL DATE <br /> \4 OS 1!!1-761 1 30,000 Regular Unleaded <br /> �ja bJ 2 30,000 Regular Unleaded <br /> 3 30,000 Premium Unleaded <br /> 7 Aos <br /> C.APPROVED PPROVED WITH CONDITIONS 0 DISAPPROVED <br /> Mtlsec, ttarhnuu(s) <br /> PLAN REVIEWE R'S NANIE DATE L 8'0 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, RULES AND <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING" 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED., I SHALL NOT EMPLOY <br /> ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br /> CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE <br /> OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' ---) <br /> Applicant's Signature __ <br /> j isle F.nvironmenLal Camp! fiance Manager Date 06/28/10 <br /> Indicate the responsible party to be billed for additional 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 /> Narne Dennis 13ock, Costco Wholesale Date 06/28/10 <br /> Nlalling Address 995, !a}:e Drive, Issaquah, WA 98027 <br /> Sis-mature _ 2-1Lw, �,, f5%zf _ Daytime Phone (425; 313-8100 <br /> Rei iced 08,,,061'09 3 <br /> 14573 006.pdf <br />