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SANJOAQUIN Environmental Health Department <br /> -� I.j t' 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 /> XTANK RETROFIT ❑ PIPING REPAIR/RETROFIT 11 UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA site # CAR000192294 Project Contact & Telephone # 425 - 251 -6222 <br /> C Facility Name Costco Gasoline ( Loc . No . 1031 ) Phone # 209 -478 - 2040 <br /> mAddress 2440 Daniels Street , Manteca , CA 95337 <br /> L _ <br /> Cross Street Airport Wa <br /> T <br /> Y Owner/Operator Costco Wholesale I Phone # 425 - 313 - 8100 <br /> C Contractor Name Phone # <br /> D <br /> T Contractor Address NOT APPLICABLE Mass <br /> R <br /> A Insurer ;ot If # <br /> TICC Technician ' s Name Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i ,e. 87 piping sump, 91 leak detector, UDC 1l2, etc. ) Installed <br /> T Gasoline Additive 1500 Gasoline Additive Mixture 5/31 /2013 <br /> A <br /> N _..... .._... <br /> K <br /> P Approved I f Approved with conditions Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name SAO Date 01 <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 � ► I aoa3 <br /> 2of6 <br />