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SANJOAQUIN Environmental Health Department <br /> UN7 Y <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS <br /> SUBSTANCES STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. <br /> INDICATE PERMIT TYPE: <br /> ❑ REMOVAL ® TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT Steven Nelson PHONE# 425 251-6222 <br /> FACILITY NAME Costco Gasoline Loc. No. 658 PHONE# 209 830-5340 <br /> ADDRESS 3250 West Grant Line Road Tracy, CA 95377 <br /> CROSS STREET South Lammers Road <br /> OWNER OPERATOR Costco Wholesale TPHONE# (425) 251-6222-1 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Jones Covey Groug, Inc. PHONE# 888 972-7581 <br /> CONTRACTOR ADDRESS 9595 Lucas Ranch Rd.000, Rancho Cucamon a,CA 917301 CA LIC# 804431 1 CLASS A B HAZ <br /> INSURER Berkshire Hathaway Homestate Insurance WORKER COMP# JOWC320551 <br /> FIRE DISTRICT South San Joaquin County Fire Authority PERMIT# F22-009 <br /> LABORATORY NAME N/A COUNTY IPHONE# <br /> SAMPLING FIRM N/A PHONE# <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39-0005182880515627 20,000 Unleaded Gasoline 7/11/2002 <br /> 39-0005182880515628 20,000 Unleaded Gasoline 7/11/2002 <br /> 39-0005182880515629 20,000 Unleaded Gasoline 7/11/2002 <br /> 39-0005182880520535 1,500 LUBRIZOL additive 5/15/2013 <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> Authorized Agent for <br /> APPLICANT'S SIGNATURE i� TITLE Costco Wholesale DATE 5/5/2022 <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME_ r DATE 5-1 22 <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> 3 of 10 <br />