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SANIJOAQUIN Environmental Health Department <br /> --- COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIRIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Carrie Miller 209-461-6337/993-4267 <br /> � <br /> Facility Name Lodi Memorial Hospital Phone#209 <br /> I Address 975 S. Fairmont St Lodi CA 95240 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Randy Roehrich Phone# <br /> 0 <br /> Contractor Name Elite IV Contractors Phone#209-461-6337/993-4267 <br /> T Contractor Address 2535 Wigwam Dr CA Lic# 1001331 Class A. HAZ <br /> A Insurer Midest Employer's Casualty Company Work Comp#BNUWC0133392 <br /> C <br /> T ICC Technician's Name Expiration Date 10/01/2019 <br /> R ICC Installer's Name Expiration Date <br /> R <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 ❑ Disapproved <br /> L eXej With Conditions) <br /> NbohPlan Reviewers Name _ _ Date L/A <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 E 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 COMPEN TIO LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFO MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ANUXLDate. <br /> w/' u/��Qppticant's Signat <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must <br /> acknowledge this res onsibility for the billing by signature and date below. <br /> NAME Carrie ler TITLE Office Manager PHONE#209-461-6337/993-4267 <br /> ADDRESS 253 Wigwam DR. Sto on C 95205 <br /> SIGNATURE DATE A <br /> 2of6 <br />