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ENVIRONMENTAL <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />n <br />(TANK RPTRORIT PqPIPINr. RFPAIR/RFTROFIT I 11C RFPAIR/RFTROFrr []COLD STARTIEVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # Dana G. Fe iock (2 0 9) 735-53 <br />A <br />Facility Name Kaiser Manteca Medical Center <br />Phone# (209) 825-3533 <br />I <br />L <br />Address 1777 W. Yosemite Ave, Manteca CA 95337 <br />TGross <br />Street ST. Dominic' s Dr. <br />Y <br />Owner/Operator Kaiser Foundation Hospital Phone# (209) 858-7836 <br />C <br />ContractorNarne Sahargun Plumbing Phone# (209) 474-2611 <br />0 <br />NContractor <br />Address 2216 Stewart St. Stockton Ca CALic#392362 Class C4,C36,HAZ <br />T <br />RInsurer <br />`travelers Insurance Work Comp # DTEUB - 4 62 0 - O S <br />A <br />C <br />T <br />ICC Technician's Certification Number Expiration Date <br />RICC <br />Installer's Certification Number Expiration Date <br />Tank ID # Tank Size Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />390002323970239701 8000 Diesel Fuel <br />Existing / 1989 <br />T <br />gal <br />A <br />N <br />K <br />g <br />P <br />EApproved ElApproved with conditions ā¯‘Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />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 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 />Project Manager <br />Applicants Signature TiNe Date <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 Dana G. Feiock TITLE Project Manager PHONE# (209) 735-5314 <br />ADDRESS 4601 Dale Rd., Modesto, CA 95356 <br />1-11 e <br />EH230038 (revised 12/31/07) <br />L4 <br />