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SAN JOAQUIN Environmental Health Department <br /> — COUNTY — <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> X TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # CAR000192294 Project Contact & Telephone # Steven Nelson ( 425 ) 251 - 6222 <br /> � <br /> Facility Name Costco Gasoline ( Loc . No . 1031 ) TPhone # ( 209 ) 825 - 8200 <br /> I <br /> L Address 2440 Daniels Street , Manteca , CA 95337 <br /> Cross Street Airport Way <br /> T <br /> Y Owner/operator Costco Wholesale Phone # (425 ) 313 - 8100 <br /> o Contractor Name Gettler- Ryan Inc . Phone # ( 925 ) 551 -7444 <br /> N Contractor Address 6805 Sierra Ct , Suite G , Dublin , CA 94568 CA Lic # 220793 Class C -61 / D40 <br /> T <br /> A Insurer Zurich American Insurance Company Work Comp # WC090463402 w <br /> T ICC Technician 's Name Matthew Campbell Expiration Date 3/ 13/2023 <br /> o <br /> R ICC Installer's Name Same as above Expiration Date Same as above <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i. e. 87 piping sump, 91 lock detector, UDC 112, otc . ) Installed <br /> T Tank 1 Fill Sump 30 , 000 87 Unleaded Gasoline 5/ 1 /2008 <br /> A Tank 2 Fill Sump 30 , 000 87 Unleaded Gasoline 5/ 1 /2008 <br /> N <br /> I< Tank 3 Fill Sump 30 , 000 91 Unleaded Premium 5/ 1 /2008 <br /> I' ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See c ent With Conditions ) <br /> A / <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WIT SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S 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." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicanl's Signature `tic ee anager / Authorized Agent Date October 29 , 2021 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank . If the party designated below is different than the permit applicant , e . g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Steven Nelson TITLE Project Coordinator PHONE # (425 ) 251 - 6222 <br /> ADDRESS 18215 72nd Avenue South , Kent , WA 98032 <br /> SIGNATUREDATE <br /> October 29 , 2021 <br /> 2o ( 6 <br />