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ENVIRONMENTAL HEALTHDEPARE&F-IVED <br /> SAN JOAQUIN COUNTY OCT 10 2016 <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 ENVIRONMENTAL HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TANK DEPARTMENT <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Megan Mitchell 209-461-6337 <br /> � Facility Name Lodi Memorial Hospital Phone# 209-339-7667 <br /> 1 Address 975 S.Fairmont St Lodi Ca 95240 <br /> L <br /> TCross Street <br /> Y Owner/Operator Randy Phone# 209-339-7667 <br /> C Contractor Name Elite IV Contractors Phone# <br /> 0 <br /> N Contractor Address 2535 Wigwam Dr Stockton CA 95205 CA Lic# 1001331 Class A-HAZ <br /> T <br /> R Insurer Midwest Employers Casualty Company Work Comp# BNUCW0133392 <br /> A <br /> C <br /> T ICC Technician's Name Expiration Date <br /> RICC installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sung,91 leak detector,UDC 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved With conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A t <br /> N Plan Reviewers Name c , Date 1 <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,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> ApplicanPs Signature TitleOffice Assistant Date 10/7/2016 <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 or_Stockton <br /> —Ca 995205 <br /> 7 <br /> SIGNATURE 1- .1.�i fiLlG[' � DATE 10/7/2016 <br /> EH230038(revised 12-11-15) 2 <br />