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SANJOAQUIN Environmental Health Department <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 /> XTANK RETROFIT a PIPING REPAIR/RETROFIT U UDC REPAIR/RETROFIT C! COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # 425 - 251 - 6222 <br /> C Facility Name Costco Gasoline ( Loc . No . 658 ) Phone # 209 -478 -2040 <br /> L Address 3250 West Grant Line Road , Tracy , CA 95377 <br /> T Cross Street South Lammers Road <br /> Y Owner/Operator Costco Wholesale Phone # 425 -313 - 8100 <br /> C Contractor Name <br /> Q Phone. # <br /> RContractor Address - NOT APPLICABLE - Mass <br /> A Insurer 10rok Compl # <br /> cICC Technician ' s Name <br /> T _ Expiration Date <br /> RICC Installer' s Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le. 87 piping sump, 91 leak detector, UDG U2, atc. ) Installed <br /> T Gasoline Additive 1500 Gasoline Additive Mixture 5/ 15/2013 <br /> A <br /> N — <br /> K <br /> P I__ Approved �_ Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name � j,1v Date.0 ( llI2023 <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 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, " <br /> Applicant's Signature Title Authorized Agent Date <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 M . Alexia Inigues TITLE Authorized Agent PHONE # 425- 251 - 6222 <br /> ADDRESS 18215 72nd Avenue South , Kent , WA 98032 <br /> SIGNATURE DATE 3 ` Ar�' <br /> 2of6 <br />