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0 <br /> SAN--*JOAQUIN EnvironmeRaIEGZV. ED <br /> COUNTY— OCT 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 /> 0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site# 44000692 ------ Project Contact&Telephone# Mike Ellis/k951)675-7233 <br /> A <br /> C Facility Nf*,me Kaiser Foundation - Manteca Phone#/209) 735-5110 <br /> 1 Address 177 Yosemite Ave., Manteca, CA 95337 <br /> L – Z <br /> T I Cross Street St .O,minics Dr <br /> I <br /> Y Owner/Operator Ka ker Foundation Hospitals hone#(510)271-5800 <br /> C Contractor Name e!�Ye hone#(949)460-5200 <br /> Environmental Services Inc. <br /> 0 BlPhone <br /> N Towne Centre Dr., Foothill Ranch, CA 92610 CA/c# 808313 Class A/HAZ <br /> T Contractor Address 25N\ <br /> R <br /> A Insurer Acord Work Comp# WCA1547285-16 <br /> C 'hQ <br /> T ICC Technician's Name Saul G zalez Expiration Date 9/23/2018 <br /> 0 <br /> R ICC Installer's Name Saul Gon lez Expiration Date 6/2/2019 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,�e\c Installed <br /> T Diesel Turbine Sump 8,000 Gallo r/ Diesel 1/1/1989 <br /> A <br /> N <br /> K <br /> A <br /> P El Approved ElXpproved with conditions Disapproved <br /> L (See A\ttahment El Disapproved <br /> With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN A ORDANCE WITH SAN JOAQUIN UNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEAL DEPARTMENT. OWNER OR LICEN D AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 9 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR ICH THIS PERMIT IS ISSUED,I SHALL T EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF ALIFORNIA." CONTRACTOR'S HIRING OR LIBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE ORK FOR WHICH THIS PERMIT IS ISSUED,\IALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> ,Applicant's Signature Title Project Ma ger Date 8/24/2018 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expend beyond permit payment coverage per <br /> tank. If the pirty 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 <br /> SIGNATURE DATE <br /> 2of6 <br />