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SAN . J O A Q U I N 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 /> ❑ TANK RETROFIT D PIPING REPAIR/RETROFIT O UDC REPAIRIRETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Bruno ESpinoza (909) 543 -8904 <br /> A Facility Name Costco Gasoline 658 Phone # (888) 972-7581 <br /> I Address 3250 W Grantline Rd . , Tracy CA 95304 <br /> L <br /> TCross Street <br /> Y Owner/Operator Phone # <br /> C Contractor Name Jones Covey Group , INC . Phone # (909) 972 - 7581 <br /> N Contractor Address 9595 Lucas Ranch Rd. , Rancho Cucamonga, CA 91730 CA Lic # $04431 Class A , B , HAZ <br /> T <br /> R <br /> A Insurer Starstone National Insurance Company work comp # T10211051 <br /> T ICC Technician's Name Raul Garcia ISSaC Expiration Date 8192172 <br /> R ICC Installer's Name Raul Garcia ISsaC Expiration Date 8192172 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T UDC #23/24 Unleaded <br /> A <br /> N - <br /> K <br /> P ❑ Approve fA roved with conditions ❑ Disapproved <br /> L I (See Ament With Conditions) <br /> A <br /> VFA 4IZ3 <br /> N Plan Reviewers Name Date " <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA CE 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: 01 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: 01 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." 'k <br /> 2 /.� 1Applicant's Signature Title Date z3 <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 Bruno Espinoza TITLE PHONE # 909 -543- 8904 <br /> ADDRESS 9595 Lucas Ranch Rd . , Rancho Cucamonga , CA 91730 <br /> SIGNATURE DATE 11 /20/2023 <br /> 7 J <br /> ? orfs <br />