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SAN . <br /> J O n O I I IN <br /> Environmental Health Department <br /> COUNTY <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 START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Carrie Miller 209461 - 6337 / 9934267 <br /> C Facility Name Lodi Memorial Hospital Phone # 209 <br /> I Address 975 S . Fairmont St Lodi CA 95240 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Randy Roehrich Phone # <br /> C Contractor Name Elite IV Contractors Phone # 209-461 -6337/ 993-4267 <br /> 0 <br /> T Contractor Address 2535 Wigwam Dr CA Lic # 1001331 Class A, HAZ <br /> A Insurer Midest Employer' s Casualty Company Work comp # BNUWC0133392 <br /> C <br /> T ICC Technician 's Name Expiration Date 10/01 /2019 <br /> RICC 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 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( 4ttachment With Conditions) <br /> A � <br /> N Plan Reviewers Name.0 <br /> ��+ 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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY THAT IN <br /> THE PERFORMANCE OF�TME 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 Signatur _ Title + � c` 1/ Date /� 6 <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 Carrie 'fer TITLE Office Manager PHONE # 209461 -6337 / 993-4267 <br /> ADDRESS 253 , Wigwam DR . Stogy on CA 95205 <br /> SIGNATURE i DATE <br /> 2of6 <br />