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EnvironmePaZGZN" <br /> SNJA0 UIN <br /> _ C O-U N T Y---- 0 C T 2 5 2018 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br /> DEPARTMENT <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# 44000692 Project Contact&Telephone# Mike Ellis/(951)675-7233 <br /> A <br /> C Facility Name Kaiser Foundation-Manteca Phone#(209) 735-5110 <br /> I Address 1777 W. Yosemite Ave., Manteca, CA 95337 <br /> L <br /> TCross Street St Dominics Dr <br /> Y Owner/Operator Kaiser Foundation Hospitals Phone#(510)271-5800 <br /> C Contractor Name Belshire Environmental Services Inc. Phone#(949)460-5200 <br /> 0 <br /> T Contractor Address 25971 Towne Centre Dr., Foothill Ranch,CA 92610 CA Lic# 808313 Class A/HAZ <br /> R <br /> A Insurer Acord Work Comp# WCA1547285-16 <br /> T ICC Technician's Name Saul Gonzalez Expiration Date 9/23/2018 <br /> R ICC Installer's Name Saul Gonzalez Expiration Date 6/2/2019 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le.87 piping sump,91 leak detector,uoc irz,etc.) Installed <br /> T Diesel Turbine Sump 8,000 Gallons Diesel 1/1/1989 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A � tlN Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK 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 /> Applicant's Signature -M& Title Project Manager Date 8/24/2018 <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 Mike Ellis TITLE Project Manager PHONE# (951)675-7233 <br /> ADDRESS 25971 Towne Centre Dr., Foothill Ranch, CA 92610 <br /> SIGNATURE mill , �&,4, DATE 11/07/2018 <br /> 2 of 6 <br />