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1 ..n u 1 vnMVC 11Milfil <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> TMS i'I_IiMii t PI RCS I5 tMS FROM IIIC AP PnOVAL DA 1L-111r1 rCATE PC F0.41r IYPE UEto'H <br /> OTANK RETROFIT OP IPING REPAIRIRETROFIT D UDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site p ProJocl Canldel&retephone#Brun❑ Espinaxa(9099 543-8904 <br /> A <br /> C Facility Name Costco Gasoline 658 PI lone 4 (8 88) 972-7581 <br /> Address 3250 W Graniline Rd„Tracy CA 95304 <br /> Crass Street <br /> T _ <br /> Y Owner/Operator Phone# <br /> a Contractor Name Jones COVey Group, INC. Phone#(909)972-7581 <br /> N Contractor Address <br /> 7 9555 Lucas Ranch Rd.,Rancho Cuc:lrtlgnga,:A 31730 CA Lie#${}4431 Class A. B, HAZ <br /> A Insurer Starstone National Insurance Company Work comp#T10211051 <br /> T ICC Technician's Name Shawn Rodriguez Expiration Date 8412602 <br /> l: <br /> ICC Installer's Narno Shawn Rod 'I uez Expiration tiata 8412602 <br /> Tank system work area Tank Size Chemicals Stored Currently Date LIST <br /> t�e,ar Plow•+�++P.S+lobi Enleriar,Unc in.elr I Installed) <br /> T 87B Tank 2 i 01- 404000 87 Gasoline <br /> A <br /> N <br /> K <br /> l' ❑ Approved Apllloved Ailh Conditions I l Disapprovod <br /> L ISae All�:lrhmenl 4Ndin Conel111ans) <br /> n ++ <br /> N Plan Roviewers Name Datn l I f i ! v", <br /> APPLICANT MUST I'MFORM ALC WORK IN ACC ON DA14CE Ylltfl SAN JO+GU IN C004 TY OHL04ktCt5 5TArE IAV4F.,AN 13 SOL F5 Atlf)NE GQI,Al IONS r)I SAN <br /> MAQUIN COUNTY,EWRONMENTAt HEAT TIi(IF 1+AR1 LIF N1 CAY4F f1 LAN i1C.FHSFn AliF rf FS tIG]IAIUpE CERTIFIES 1)1F FIA 1.OW <br /> Jun 't CFR}IFy rllAF iN <br /> THE PERFORMANCE of 1 HE WORK FPR W111CH THIS PEk\411 t515SU Co.I SHALL NOF EAIr1py Atrr PERSON NI SUQI A I.WINER A5 TO nECOME SUIIJE CT T[) <br /> WORKLH's COMPENSATION LAWS Of CMIroNi,iw, LFII RACI C4(5 11+N WG 09 SUOCC04 T RACT 1146.irit'IATUH£CUI IIF I E 5 fflE FOLLOWiN4 't CEN rIFy <br /> MAT IN THC PC RFORMANC[of 11 IC K FOIL 55 liC)I I15 PERMIT 1S IS5UE13.I Sl tut EUFILOY PER90t15 SU9JVGT TO WORXEIrS MMPENSAIKit I LAWS <br /> OF C&IFORNIA' <br /> RI+P¢nnt'�Slip lulu T,.Jones Cordy GfouP P6rmltling n,n 11MQ022 <br /> BILLING INFORMATION: <br /> Indicnto(ho rosponsibio pnrly to be bttltid for addllional EHO staff time uxpendeo beyond permit paymem coverage per <br /> tank. II Iho party designated below is different than the permit appicant, e.g. properly owner, the party must <br /> acknowledge Ihis ros ponsl bility for tha billing by signature and dace below, <br /> Nair-_ Bruno Espinoza 11ILE Jones Covey Group-Pefm run9 P}4414E x 909-543-8904 <br /> ADDRESS 9595 Lucas Ranch Rd.. Rancho Cucamonga,CA 91730 <br />