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;HEGhE1fE: <br />ENVIRONMENTAL HEALTH DEPARTMENT JUN 9 4 201' <br />SAN JOAQUIN COUNTY aNVIRONMENiA <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 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 />1Z TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Liddy McKenzie (925.551.7555) <br />A <br />C <br />Facility NameKAISER HOSPITAL MANTECA <br />Phone # <br />I <br />L <br />Address 1777 W. YOSEMITE AVE <br />TCross <br />Street <br />Y <br />owner/operator KAISER MEDICAL GROUP <br />Phone # <br />C <br />Contractor NameGettler-Ryan Inc <br />Phone # (925) 551-7555 <br />T <br />Contractor Address 6805 SIERRA CT, SUITE G, DUBLIN, CA94568 <br />CA Lic # 220793 Classa,a,C,o.C5 .C-611040.HIC <br />A <br />Insurer State Compensation Ins Fund <br />work comp # 9051229-3 <br />T <br />ICC Technician's Name CHRIS SAN NICOLAS <br />Expiration Date 03/17/2017 <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />- 1 <br />N <br />K10 <br />�� 1 <br />P <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <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." <br />��- <br />Applicant's Signature Title AGENT FOR OWNER Date06/19/2015 <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 />NAMEMERLIN BOWEN TITLE Project Manaqer PHONE #925.551.7555 <br />ADDREss6805 SIERRA CT. SUITE G. DUBLIN, 94568 <br />SIGNATURE <br />EH230038 (revised 02/20/09) <br />1 <br />