Laserfiche WebLink
Vi TL HEALTH DERkRTMENT <br /> SAN JOA UIN COUNTY <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (209) 3420 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW: <br /> UTANK RETROFIT xkJmPiNG REPA[R/REIRcFIT UUDc REPAIRtREIRoFiT UCOLD START/EVR UPGRADE <br /> F EPA site# Projea Contact 8,Telephone# Jesse 209-367-4800 <br /> C Facility Nam SJ General Hospital Phone t 209-468-6166 <br /> � Address 500 W. Hospital Rd, French Camp, CA 95231 <br /> TCross Street I-5 <br /> Y OwnerlOperator San Joaquin General Hospital Phone# 468-6166_ <br /> o contractor Nam Jose h Bajzlev Phone# 209-367-400 <br /> Contractor Address 2370 Maggio Cir, #4 Lodi 94240 TCA tic#774802 CWSSB C61 D3 <br /> A Insurer Monroe & Monroe - General LiabilitV mrk ComP#WEN004519701 <br /> T ICC Technicians Certification Number 80. 14628-UT Expiration Date Nov 18 2010 <br /> T <br /> R ICC Installer's Certification Number 801 628-U1 Expiration Date July 31, 2010 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Curr enty/Prevlau* <br /> T 4#1 10,000 #2 Diesel <br /> A <br /> N <br /> K <br /> P UApproved LlApproved with conditions UDisapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Data <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 LI AGENT'S SIGNATURE(CIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE V40RK FOR WHICH THIS PERMIT IS ISSUED,I SHALJ_NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF IA." CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE CE THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> CE CALIFORN(A" <br /> e Td. Pro 'ect Manager 4/2/09 <br /> BILLING INFORMATION: <br /> Indicate the rhsible party to be billed 1br additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit appkant. e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Jesse Berumen TITLE Project Manager PHONE# 209-367-4800 <br /> Contractor for SJ Gen Hospital <br /> ADDRESS 2370 Maggio Cir., #4, Lodi, CA 95240 <br /> SIGNATURE <br /> EH230038( 12131107) <br /> 1 <br />