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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <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 REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Megan Mitchell 209-461 -6337 <br /> A <br /> C Facility Name Lodi Memorial Hospital Phone # 209-339-7667 <br /> I Address 975 S Fairmont Ave Lodi Ca 95240 <br /> L <br /> TCross Street <br /> Y Owner/Operator Randy Phone # 209-339-7667 <br /> Q Contractor Name Elite IV Contractors Phone # 209-461 -6337 <br /> O <br /> N Contractor Address 2535 Wigwam Dr Stockton Ca 95205 CA Lic # 1001331 Class A-HAZ <br /> T <br /> R <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC0133392 <br /> TICC Technician 's Name Expiration Date <br /> RICC Installers Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, uoc 12, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ei achment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date 'AZ <br /> l <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA E 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 /> Applicant's Signature 7e4 Title Office Assistant Date / <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 /> NAME Megan Mitchell TITLE Office Assistant PHONE # 209-461 -6337 <br /> ADDRESS 2535 Wigwam Dr Stockton ca 95205 <br /> SIGNATURE DATE <br /> EH230038 (revised 12-1 1 -1 5) 2 <br />