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i Costco Fuel Facility#1091 Lodi, CA/ BCE#14573.11 j ❑ New Facility � Existing Facility /Nu dz S� i San Joaquin County Environmental Health Department Application Form Facility Name Costco Fuel Facility LOC. 1091 Site Address City State ZIP 2680 Reynolds Ranch Parkway Lodi CA 95240, APN Supervisor District Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner IX Repairs or Remodel .Q Other Requested Operating Permit RETROFIT / Comments UST Retrofit Permit Application for expansion of existing fuel facility If mobl a oo ruc o VIN pwnper truck Contact Types IN Billing Party 13& Facility Owner ❑ Facility Contact ❑ Property Owner 121 Contractor ❑ Architect required ` Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Architect First Name Last name /; If contrac or, indicate type and license number Alexia Inigues Address Costco Wholesale Corporation c/o Barghausen Consulting Engineers, LLC City State ZIP 18215 72nd Ave S Kpnt WA 98032 Phone Phone Email (425) 251 -6222 costco@barghausen.com ❑ Billing Party ❑ Facility Owner ❑ Facility Contk1 ❑ Property Owner Contractor ❑ Architect First Name Last name If contractor, indicate type and license number Umang Sin h 300345, A C21 C10 B C61/D40 C57 Address City State ZIP Wayne Perry, Inc., 8281 Commonwe Ave Buena Park CA 90621 Phone Phone Ema 714 826-0352 u �@wpinc.com ❑ Billing Party Facility Owner Facility Contact ❑ Property Owner El Contractor ❑Architect First Name Last name If contractor, Indicate type and license number Cody McKenna Address 7 City State ZIP Costco Wholesale Cor or4'tion, P.O. Box 35005 Seattle WA 98124 Phone Phone Email 425 313-8100 costco@barghausen.com BILLING ACKNOWLEDGEMENT: I, +he undersigned property or business owner, operator o<iVIhorized ages-j f same, acknowledge that all site and/or y specific ENVIRONMENTAL HEAL DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identifi nn form. I also certify that I have pre ared this application and that the work to be performed will be done In accordance with all SAN JOAQUIN COUNTY Ordinance CTIe ' CD Standards,STATE and FE RAL laws. IF 6/16/2025 AN C APPLICANT'S SIGNAT E: DATE: , Authorized Agent for Cost ❑ PROPERTY/ B/U9 fNESS OWNER ❑ OPERATOR/MANAGER W OTHER AUTHORIZED AGENT Wholesale Corporation &.-D�O / Title �rvd CO If APPLICANT/'�� not the BILLING PARTY, proof of authorization to sign is required /•/ F AUTHORI�ZA�`TION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the above site address, hereby autho release o,f✓ar' and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART, ENT as soon as It is available and at the same time it is provided tome or my representative. Accepted By Assigned o Linked FA ID S�ZMC " 2uQ ��Z A JN Date I� 2 PE n (? Fee / Record Number G �5 lIJ /�� SRa501a00 ❑ Cash ❑ Check# kConflrmatlan# Q) L-�7' � 9� 2 Payment c, Received By Rev 07/10/2024