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ENVIRONMENTAL HEALTH DEPART f ..:,N . <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 APR 14 2016 <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# Carrie Miller 209-461-6337 <br /> A <br /> C Facility Name Lodi Memorial Hospital Phone# 209-334-3411 <br /> 1 Address <br /> L 975 S.Fairmont St. Lodi,CA <br /> I Cross Street <br /> T <br /> Y Owner/Operator Randy Phone# 209-339-7667 <br /> C Contractor Name Elite IV Contractors Phone# 209-461-6337 <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr. Stockton CA Lic# 1001331 Class A-HAZ <br /> A Insurer Midwest Employers Ompany Work Comp# BNUWC0133392 <br /> C <br /> T ICC Technician's Name UAd u 01 1 N. Expiration Date <br /> 0 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112.etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions i—I Disapproved <br /> L S Attachment With Conditions) <br /> A i <br /> N 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 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 /> Appllcanrs Signature Title <br /> Office Manager Date 4/14/16 <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 Elite IV Contractors/Carrie Miller TITLE Office Manager PHONE it 209-461-6337 <br /> ADDRESS 2535 Wigwam Dr. Stockton, CA 95205 <br /> SIGNATURE ,Zz DATE 4/14/16 <br /> EH230038(revised 07-17-2014) <br /> i <br /> 2 <br />