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9 • <br />ENVIRONMENTAL HEALTH DEPAFRftLC:i <br />SAN JOAQUIN COUNTY VED <br />1868 E. Hazelton Ave., Stockton, California 95205 NOV 2 6 2014 <br />Telephone: (209) 468-3420 Fax: (209) 468-343L�NV1E <br />APPLICATION FOR UNDERGROUND STORAGE TANK DEPAR7-Vd ,�,,, <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPASite# CAD983600594 <br />Project Contact&Telephone# Mike Ellis (951) 6785-7233 <br />C <br />Facility Name Kaiser Stockton Medical Center <br />Phone# 209-476-5408 <br />I <br />L <br />Address 7373 West Lane Stockton, CA 95210 <br />TCross <br />Street <br />Y <br />Owner/Operator Kaiser Hospital Foundation <br />Phone# 209-476-5408 <br />0 <br />0 <br />Contractor Name Belshire Environmental Services, inc <br />Phone# (949) 460-5200 <br />N <br />Tqri <br />Contractor Address25971 Towne Centre Dr. Foothill Ranch, CA <br />CA Lic # 808313 ClassA/Haz <br />A <br />InsurerGreat Northern Divide Insurance Co <br />Work Comp #WCA1547284-12 <br />T <br />ICC Technician's Name Dave Walker <br />Expiration Date 01 / 02 / 2 016 <br />O <br />R <br />ICC Installer's Name Dave Walker <br />Expiration Date 03/06/2016 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />Monitoring System <br />Diesel <br />T <br />A <br />N <br />K <br />P <br />❑ Approved �pproved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name �i/V1��I , "� Q�ZiI f, Date I <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 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 />77 <br />Applicant's Signature %ac& ElUk Title Project Manager Date 11/4/2014 <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 />NAMEBelshire Environmental services, inc. TITLEProject Manager PHONE# 949-460-5200 <br />ADDRESS 25971 Towne Centre Dr., Foothill Ranch, CA 92610 <br />SIGNATURE "elEltflk DATE 11/4/2014 <br />EH230038 (revised 07-17-2014) <br />2 <br />