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ENVIRONMENTAL HEALTH DEPART IV [) <br /> SAN JOAQUIN COUNTY' OCT 09 2015 <br /> 1868 E.Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 ENVIRONMENTAL <br /> HPVrILI nP0A0T4ACKIT <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 El PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Carrie 461-6337 <br /> A <br /> C Facility Name Lodi Memorial Hospital Phone# 209-339-7667 <br /> I Address <br /> L 975 S.Fairmont Lodi,CA 95240 <br /> Cross Street <br /> Y Owner/Operator Rand Phone# <br /> C Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr. CA Lic# 1001331 Class A-yAz <br /> A Insurer Berkleynet Work Comp# BNUWC0133392 <br /> T ICC Technician's Name Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (1.&87 Piping sump,01 leak detector,UDC 112,eta) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L h t With Conditions) <br /> A I(� <br /> N Plan Reviewers Name -- - - Date. 7'(�\�/ <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 AGENTS 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 /> plicarft Slanature a 1'� CG, Tice Office Manager Date 9/10/15 <br /> BILLING INFORMATION.' <br /> Indicate the responsible party to be billed for additional EHD staff'time expended beyond permit payment coverage per tank. If <br /> the party designated below is ;different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Elite IVCOntractors TITLE Office Manger PHONE# 209-461-6337 <br /> ADDRESS 2535 V wam Dr. Stockton CA <br /> SIGNATURE WWA4.1DATE 9/10/15 <br /> EH230038(revised 07-17-2014) <br /> 2 <br />