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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 EastMain t li r is 95202 <br /> Telephone: ( ) - : ( )468-3433 <br /> APPLICATION I PIPING 1PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFITVIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR <br /> F EPA Site# Project Contact&Telephone#Jesse 209-367-4800 <br /> A <br /> Facility Name San Joaquin General Hospital Phone#209-468-6166 <br /> L Address 500 W. Hospital Road French Cam CA 95231 <br /> T Cross Street I-5/Matthews Rd <br /> Yowner/operator San Joaquin General Hospital Phone# James Karo 468-6166 <br /> C Contractor Name Joseph Bagley Phone# 209-367-4800 <br /> O <br /> N <br /> r Contractor Address 2370 Maggio Cir., Unit 4, Lodi CA Lic# 774802 ClassB,C61(D21,D3 ,DW) <br /> A Insurer Monroe & Monroe - General Liability Work Comp#WEN004519701 <br /> T ICC Technician's Name Jesse Berumen 8014628-UT Expiration Date Nov 18, 2010 <br /> O <br /> R ICC Installer's Name Jesse Berumen 8014628-U1 Expiration Date Jul 31 2010 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping surnp,91 teak detecW.UDC 12,etc) Installed <br /> T #1 10,000 #2 Diesel <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <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 <br /> TO 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 /> Applicants s re Title Contractor Date 4Z10/09 <br /> BILLING INFORMATION: <br /> Indicate the responsfie 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. Contractor for <br /> NAME Joseph Bagley TITLE SJ General Hospital PHONE# 209-367-4800 <br /> ADDRESS 2370 Maggio Circle, Unit 4, Lodi, CA 95240 <br /> SIGNATUIRE F DATE 051CI*4200 <br /> EH230038(revised 02120/09 <br /> 1 <br />