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SANJOAQUIN Environmental Health Department <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRE=S 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETRoriT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Bruno Espinoza (90 9) 543-8904 <br /> C Facility Name Costco Gasoline 858 Phone# (888) 972-7581 <br /> 1 Address 3250 W Grantline Rd., Tracy CA 95304 <br /> I Crass Street <br /> T <br /> Y Owner/Operator Phone# <br /> o Contractor Name Jones Covey Group, INC. Phone# (909)972-7581 <br /> T Contractor Address 9595 Lucas Ranch Rd.,Rancho Cucamonga,CA 91730 CA Lic#804431 Class As B HAZ <br /> R Insurer Starstone National Insurance Com an Work Comp#T10211051 <br /> T ICC Technician's Name Shawn Rodriguez Expiration Date 8412802 <br /> R ICC Installer's Name Shawn Radri ueZ Expiration Date 8412602 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le-87 plping sump,91 laakdetector,JDC 712,etc.) Installed <br /> T 87B Tank 2 10'- 40,000 87 Gasoline <br /> A <br /> N <br /> K <br /> Ia n Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A ��7] <br /> L• <br /> N n7 ^L <br /> Pian Reviewers Name Date A. <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH 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 SUBJECTTO <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 /> Applicant's Signature Title Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional E H D 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 10/27/2022 <br /> 2 of 6 <br />