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01/15/2002 02:43 2093397651 LMH MTC SHOP PAGE 03/05 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> D <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 R E 6, V !,l` <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 T 1 2 017 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENIAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS PROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW! DEFARTI` ENT <br /> OTANK RETROFIT 0 PIPING REPAIRIRETROFIT OUDGREPAIR/RETROFIT 0 COLD STARTIEVR UPGRADE <br /> P! EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name Lod Memorial Hospital Phone# 209-339-7667 <br /> Address 975 S Fairmont Lodi Ca 95240 <br /> L <br /> T I Cross Street <br /> y Owner/Operator Randy Phoneffi 20A <br /> 9-339-7667 <br /> 0 Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> T <br /> N A,HAZ <br /> Contraotor Address r <br /> R wam Dr Stet Ca 9 CA Lie# 1001331 class <br /> 20_, <br /> AIneurerMidwest Emal Company Workrornp# BNUW00133392 <br /> C <br /> T [CC Technician's Name Expiration Date <br /> ICC Installer's Name Expiration Dale <br /> Tank system work area Tank Size Chemicals Stored Currently Data LIST <br /> ILA.07 p1p1np surto.at Ink dRIPCIrr,VOC,112,AM) Installed <br /> T <br /> A <br /> M "I'll, . I.......... <br /> K <br /> P ❑ Approved ❑ Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERPORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANOr$,STATE LAWS,AND RULES AND REGULATIONS,OF SAN <br /> OAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT,OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING! 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 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 INTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT 70 WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> jApplinni'a SfqrA1(r((%. q MeLhdl Till =3=17— <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 acknopAedge this <br /> rosponsibillLy for the billing by signature and data below, <br /> NAME JUegaaJAftch.e,lI TITLE—Office Assistant PI-IONE 9—ZOk-AW—M.37 <br /> AODREss 2535 VVjg-AL4MQr_Stockton Ca 952Q5 <br /> SIGNATURE ki 1 tti d. ...... —DATE 1d 3QL2-0j <br /> _7, <br /> EH230038(rfticed 12-11.1 b) 7 <br />