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SANJOAQUIN Environmental Health Department <br />COON 1-Y <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 />❑ TANK RETROFIT Cl PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Bruno Espinoza (90 9) 543-8904 <br />A <br />C <br />Facility Name Costco Gasoline 658 <br />Phone # (888) 972-7581 <br />1 <br />Address 3250 W Grantline Rd., Tracy CA 95304 <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator <br />Phone # <br />C <br />Contractor Name Jones Covey Group, INC. <br />Phone # (909)972-7581 <br />T <br />Contractor Address 9595 Lucas Ranch Rd., Rancha Cucamonga, CA 91730 <br />CA Lic # 804431 Class A B HAZ <br />> > <br />R <br />Insurer Starstone National Insurance Com an <br />Work comp # T10211051 <br />T <br />T <br />ecnician's Name <br />h N <br />ICC TShawn Rodriguez <br />Expiration Date $412602 <br />R <br />ICC Installer's Name Shawn Rodri ueZ <br />Expiration Date 8412602 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date LIST <br />(I.e.87 plping sump, 91 laakdatedor, IJDG 712, etc.) <br />Installed <br />T <br />87B Tank 2 <br />10'- 40,000 <br />87 Gasoline <br />A <br />N <br />K <br />p <br />i� Approved Approved with conditions U Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />��4L <br />Plan Reviewers Name '' Date lI G' 'G' <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 THtS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA' <br />Applicant's Signature Tltie 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 Bruno Espinoza <br />TITLE PHONE # <br />ADDRESS 9595 Lucas Ranch Rd., Rancho Cucamonga, CA 91734 <br />SIGMA <br />2 of 6 <br />909-543-8904 <br />10/27/2022 <br />