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S A ,J GAO U IN EnTTECE,T aT D <br /> COUNTY— <br /> APPLICATION FOR UNDERGROUND STORAGE TA C T 18 2018 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> FFM RV &W <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PE �IRQ . ENTAL HEALTH <br /> 0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT 0 COLD _" <br /> "A �W"F"-XDE <br /> F EPA Site# Project Contact&Telephone# Carrie Miller 209461-6337/993-4267 <br /> A --T— <br /> C Facility Name Lodi Memorial Hospital Phone#209 <br /> I <br /> L Address 975 S. Fairmont St Lodi CA 95240 <br /> 1 Cross Street <br /> T <br /> Y Operator Randy Roehrich Phone# <br /> C Contractor Name Elite IV Contractors Phone#209-461-6337/9934267 <br /> 0 <br /> N <br /> T Contractor Address 2535 Wigwam Dr CA Lic# 1001331 Class A,HAZ <br /> R <br /> A InsurerMidest Employers Casualty Company Work Comp#BNUWC0133392 <br /> C <br /> T ICC Technician's Name Expiration Date 10/01/2019 <br /> ' I ICC Installers Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping surnp.91 leak detector,UDC W,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P El Approved El Approved with conditions El Disapproved <br /> L (See Attachment With Conditions) <br /> A <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCEE OF � WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> COMP <br /> IT <br /> M <br /> WORKER'S FEN ;TIOLAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: I CERTIFY <br /> THAT INIFO MAN 6E OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL E LOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> HE <br /> OF CALIFORNIA." a. T/owt-Date <br /> ,AppficaniSignatu <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 responsibility for the billing by signature and date below. <br /> NAME Carrie Miller TITLE Office Manager PHONE#209-461-6337 9934267 <br /> ADDRESS— 2535 Wigwam DR. Stockton CA 95205 <br /> SIGNATURE DATE <br /> 2 of <br />