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SANJOAQUIN Environmental Health Department <br /> C: 00NIY <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 ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT N COLD STARTIEVR UPGRADE <br /> F EPA Site # CAR000227926 Project Contact & Telephone # 425- 656- 1064 <br /> C Facility Name Costco Gasoline ( Loc . No . 38) Phone # 209-478-2040 <br /> I <br /> L Address 1630 East Hammer Lane , Stockton , CA 95210 <br /> TCross Street West Lane Frontage Road <br /> Y Owner/Operator Costco Wholesale Corporation Phone # 425-313-8100 <br /> c <br /> 0 Contractor Name Wayne Perry Phone # 714-826- 0352 <br /> N Contractor Address 8281 Commonwealth Ave , Buena Park <br /> T CA Lic # 300345 ClassHAZ C5740' <br /> A Insurer Everest Indemnity Insurance Work Comp # CA10003737231 <br /> T ICC Technician 's Name Gabriel Venegas , ICC CERT #8787964 Expiration Date 06/16/2025 <br /> R ICC Installer's Name N/A Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112 , etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L <br /> A (See Attachment With Conditions ) <br /> N i <br /> Plan Reviewers Name (A t` 1 LOKZ Date y / IS / "Z �f <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 WOR FIS OR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." 11L —� <br /> Applicant's Signature , thorized Agent Date 3/25/2024 <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 3/25/2024 <br /> 2of6 <br />