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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave , , Stockton , California 95205J / q <br /> Telephone : ( 209 ) 468-3420 Fax : (209 ) 468 -3433 A ) <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ) <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Terry Master 209461 -6337 <br /> A Facility Name Dignity Health - St. Joseph ' s Medical Center Phone # 209-943 -2000 <br /> I Address $969-eenietet=y-L e Stockton , CA 95204 j ` CO J /pti ih <br /> I Cross Street <br /> T <br /> Y Owner/Operator John Stagg Phone # 209461 -6818 <br /> `✓ Contractor Name Elite IV Contractors Phone # 209-461 -6337 <br /> O <br /> T Contractor Address 2535 Wigwam Dr. Stockton CA 95205 CA Lic # 1001331 Class A - HAZ <br /> A InsurerMidwest Employers Casualty Comapny Work Comp # BNUWC0133392 <br /> T <br /> r ICC Technician's Name Expiration Date <br /> R <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> I <br /> P ❑ Approved pproved with conditions El Disapproved <br /> L A achment With Conditions) <br /> A <br /> N Plan Reviewers Name Date V2 <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 COMPENSATIO CAWS OF CALIFORNIA. " CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMAN t E 01 <br /> 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 <br /> Title Office Manager Date 7/24/2019 <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 Elite IV ntr . ctors/ Carrie Miller TITLE Office Manager PHONE # 209-461 -6337 <br /> ADDRESS 253 Wigwam Dr Tdbktc1,PVt. A <br /> SIGNATURE i <br /> DATE 7/24/2019 <br /> r <br /> EH230038 ( revised 07A7-2014) <br /> 2 <br />