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n1 . �.vn• rvly r V1♦ a I Wr%M%3G I M$NF% <br />RETROFIT OR PIPING REPAIR PERMIT <br />TI 118 PE 11MIT C Pin F:i IW111 A1'5I P U M IIIc AP PH OVAL UA rL. VIC 11 i,AIE PCH Ir I'fPE BELOW <br />0 TANK RETROFIT 0 PIPING REPAIRIRETROFET D UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br />r <br />EPA spelt PraJocl Danla[I & Totsphane N Bruno ESpint]Za (909) 543-8904 <br />A <br />C <br />Facility Name Costco Gasoline 558 Phone # (888) 972-7581 <br />Address 3250 W Grantline Rd„ Tracy CA 95304 <br />Cross Street <br />Y <br />Owner/Operator Phone # <br />0_J_ <br />Contractor Name Jones Covey Group, INC. <br />Phone # (909)972-7581 <br />R <br />T <br />_ <br />Con Address 9595 Lucas Ranch fid„ Rancho Cur']nrpnga, CA 31730 CA Lic p ${}4431 Glass A. B, HAS <br />A <br />Insurer Starstone National Insurance Company Work comp # T10211051_ <br />U <br />T <br />ICG TechnIclan's Name Shawn Radri 9 uez Expiration Date 8412602 <br />q <br />ICC Installer's Name Shawn Rodri uez Explralion Data 8412602 <br />Tank systoin work arca Tank Slxe <br />[!�•a,pipnq_P,v11-haulcela..unLrr n.1 <br />Chemicals Stared Current! y <br />Dale LIST <br />Installed <br />T <br />8713 Tank 2 10'- 40,000 <br />87 Gasoline <br />A <br />N <br />K <br />P I I Approved DIY Ailtslovdd with cpndiIIons I Dis;lpprovud <br />L ISoo Alla0manl W1fh Com nitlons) <br />A <br />��77 <br />N Plan Reviewers Name �—r` Uata I I f i i 2,, <br />APPLICANI MIDST PERFORM At. I. WOKK IN Aek. OII ELANU Vol I SAI: A+OU IN C9LIN r4'01 W114ANGf. 5. 51 ATE LAw5. Arm RULES ANI` HEdUL AT IONS SAN <br />JDApUIN COUNTY, CNVIRONMENW. IIF Ai I II DEI'ARIME"I L,.V4FH rII L1CI:fl-TFa 49-tPYr5 51Fy'IAtUNE' CERTIFIES INF FCx.i3OWIIJri '1 CrrifiFy <br />IFIAI IN <br />THE PE.RFCRMANCE OF ]HE WORK POR W I04 THIS PERMIT 1S ISWIFU I SWILL NOS EA 11610 AJIY PERSON Irl SUL:R A MANNER AS TO FIECUME SUIIJECr Fr.) <br />WORKER'S COMPENSAIION LAWS OI' CAIWORNIA.- CON1RACtUI5 II -.14117G OR SUBCCNTRACT1140 StrNATORf CCRTIv IE5 TRE FOLLOW1fIG 'I CEknr y <br />tIIAT IN THE PERTORMANC[ or 1fiE K FON L1711CH IHr5 PERMIT Iy ISSUED I Sf(AIL EIJPIIJ'r PEMOfIS 5U9J£G7 To W0 jtI(EI;rj t:S)MnEtI'SAII6N LAW!, <br />Or CALIFORNIA' <br />ArydlcdnPt slgsuilwn r„,„ Jones cavey Group Pv"mltling I.Ia,� 1l,Z V2022 <br />BILLING INFORMATION <br />hldicntu Iho responsIblo parly to ba billed for add llional EH❑ tiIatf {Ima uxpend00 hey(xld p ermlI {-aymenT COV41age per <br />lank. II Ileo early deslgllalad h0ow IS different than the permit appfrant, e.g. pruporly cr"er. the party must <br />acknoWedge Ihis res ponslWily far the billing by Signature and date hclflw, <br />NMIF Bruno Espifloza TITLE- Jones Covey Group - PLfm,"1ng P}tOtdE a 909-543-8904 <br />ADDRESS 9595 Lucas Ranch Rd., Rancho Cucamonga. CA 91730 <br />