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i <br /> SANJOAQUIN Environmental Health Department <br /> C 0 t_1 f',l T Y Costco Fuel Facility#1091 /Our Job No. 14573.11 <br /> I <br /> i <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> El REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA ID# PROJECT CONTACT IPHONE# <br /> FACILITY NAME Costco Fuel Facility (Loc. 1091) JPHONE# <br /> ADDRESS 2680 Reynolds Ranch Parkway, Lodi, CA 95240 <br /> CROSS STREET Reynolds Ranch Parkway and East Harney Lane <br /> OWNER OPERATOR Alexia Inigues PHONE# (425) 251-6222 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Wayne Perry Inc. PHONE# (714)826-0352 <br /> EMAIL ADDRESS wfriesen@wpinc.com CA LIC# 300345 1 CLASS A, C21, C10, <br /> INSURER C57 WORKER COMP# WC6833416-01 B, C61/D40, Haz, C57 <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME(,ql%6AM Lc�bOr�l y 5tnv;--L(_5 ELAP ID#: j 33 PHONE#(j`Z)69,3-7 j 0 L <br /> LABORATORY ADDRESS; Z4q �t �,� food 9,v060 CordAov0. CA Q514Z <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 4 1,500 Ultrazol GA9058 fuel additive 2/5/13 Date in operation <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE Authorized Agent DATE 4/14/2026 <br /> KAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/ R ON ATTACHMENT) <br /> PLAN REVIEWER'S SIGNATURE DATE_/ 1/4-/14, <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK, <br /> 1 <br />