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• 0 <br />4RONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility Name San Joaquin General Hospital <br />Phone # 209-468-7063 <br />i <br />L <br />Address 500 W. Hospital Rd, French Camp CA <br />TCross <br />Street <br />v <br />Owner/Operator San Joaquin General Hospital <br />Phone # <br />c <br />Contractor Name '8a#1ey Enfteprr f*, Inter. <br />Phone # 209-367-4800 <br />0 <br />T <br />Contractor Address 2370 Mag#i&Ctr, Ste,4, Lo (4 95240 CA Lic# 774802 Class <br />R <br />A <br />Insurer Berkley Net <br />Work Comp # 7,36749 <br />T <br />ICC Technician's Name je§j&SerU,,rne4V <br />Expiration Date 6/9/20.18 <br />O <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(Le. 87 piping sump, 91 Ink detector, uoc 1)2, etc.) <br />T <br />20,000 <br />Diesel <br />A <br />N <br />K <br />Po <br />❑ ApprovedApproved with conditions ❑ Disapproved <br />L <br />(S Attachment With Conditions) <br />a <br />A <br />N <br />y A <br />� �-T12��2�f7 <br />- <br />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 AGENT'S 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." m <br />Applicenre Sign epure Title C��'° <br />'7 ` BILLING INFORMATIQN: r, <br />Indicate the responsible party to be billed for additional EHID staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the billing by signature and date below. <br />NAMET JVB , Ba N £yLizy'pri , b+lt+EB �enerocLMayLa�er PHONE 1t 209-367-4800 <br />2370 Mage-i&C%r, Stpi4, Lodiy CA 95240 <br />SIG <br />EH230038 (revised 07122110) <br />DATE G?/dir/--t,vJ -7 <br />RE' -k -'11"%'W-"! <br />ENVIRONMENTA ._ y_1 :t x+ i <br />DEE-A,P-7r0iF"i.E <br />,Za40 <br />