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SANJ O A Q U I N Environmental Health Department <br /> COUNTY <br /> Received <br /> APPLICATION FOR UNDERGROUND STORAGE TANK 9/28/2023 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Robert Sills ( 714 ) 9754257 <br /> A <br /> O Facility Name Costco Gasoline 658 Phone # ( 888 ) 972 - 7581 <br /> � Address 3250 W Grantline Rd , Tracy CA 95304 <br /> 1 Cross Street <br /> T <br /> Y Owner/operator Costco Wholesale Corp Phone # (425 ) 251 - 6222 <br /> o Contractor Name Jones Covey Group , Inc . Phone # ( 909 ) 972 - 7581 <br /> T Contractor Address 9595 Lucas Ranch Rd # 100 , Rancho Cucamonga , CA 91730 CA Lic # $ 04431 Class A , B , Haz , Can 10 <br /> A Insurer Starstone National Insurance Company Work Comp # T10231330 <br /> T ICC Technician' s Name Justin Zorn Expiration Date 9157862 <br /> R ICC Installer's Name Justin Zorn Expiration Date 9157862 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T T1 87A 20 , 000 87 Gasoline <br /> A <br /> N <br /> K <br /> P Ll Approve Approved with conditions ❑ Disapproved <br /> L (Se Att h ent With Conditions) <br /> A <br /> N Plan Reviewers Name I Date ` Lt � 2f Z�j <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORD AN QUIN 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." s <br /> Applicant's Signature it) s ' Title Permit Team Date 9/28/2023 <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 Robert Sills TITLE Permit Team PHONE # 714 - 975 - 4257 <br /> ADDRESS 9595 Lucas Ranch Rd . , Rancho Cucamonga , CA 91730 <br /> SIGNATURE 10DATE 9/21 /2023 <br /> 2 of 6 <br />