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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3m FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW. <br /> _TANK RETROFIT_PIPING REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> #_____________________ --------------____________________________________ ______________-__________________________- <br /> EPA <br /> --- ---- x I PROJECT ------T --------- - Joy-Bag"3--367--48W-----------------I <br /> 1 1TELEPHONE <br /> --- SITE - -- TETT - - - -- - ----------- CONTACT-- TELE-HONE - - <br /> F : FACILITY NAME - Tracy_Unified_School_District_Mot4S_P991_______ _°_sem g831-5051__________________; <br /> 1 A +_________ <br /> 1 c : ------s 197_5_W.-Lowe ll-Ayenue------------ ra9-y,--CA_25.37fL------------------------------------------------- <br /> L : CROSS STREET <br /> I +------TETTTETT-TETT-- ------------------------------------------------ <br /> ------------------------------ <br /> I Y i racy�nlfied School District i P831 5051 <br /> ' + - - - -- - ----------------------------------------------------- +---------------------------- <br /> i C : CONTRACTOR HAKE Bagley EnterpgEIes, Inc. PAO"$ # 367-4800__________________; <br /> o +TETT---TETT-- ----------TETTTETT-----TETT-- ' <br /> N : CONTRACTOR ADDRRSS 2370 Maggio Cir, //4, Lodi 95240 1 CA LIC # 774802CLAS_sB, _C61(D21_ILD34j_�40) <br /> R : INSUBRR Monroe @ Monroe Insurance 1 RaR%.CON"41788626_200_5___________; <br /> I c 1 � INFORMATIONGeneral Liability 4f02-GL589707 <br /> T : -# <br /> 0 : PHONE I{ <br /> A # # <br /> , <br /> PROWS p <br /> , <br /> , <br /> ________________________________i_____________________________________ ___________ <br /> TAN% IDP TANK SIZE CHRMIrAT.a STORED CORREiTLY/PREVIOUSLY 1 DATE GET INSTALLED <br /> 39- <br /> T 1 39- <br /> A 1 39- <br /> 1 N 1 39- <br /> 1 R : 39- <br /> I 1 <br /> I P I <br /> 1 L 1 APPROVSO ( 'APPROVED HIM CONDITIONS) DISAPPROVED" <br /> I A : 11 (S ATTACHMENT KITH CONDITIONS) <br /> N PLAN RSVIUj <br /> RNRRE SAKE -NG DATE <br /> APPLICANT MUST PERFORM ALL NOR% IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DBPARMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: °I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE NOR% FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANGER AS TO <br /> BECOME SUBJECT TO WORKER'S SATION LAWS OP CALIFORNIA.° CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWTH <br /> FOLLOWING: °I CERTIFY THAT IN THE PORMANCB OP E NOR% POR CH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OPCALIPO SIA..,°�.f�/\) <br /> APPLICANT'S SIGNATURE: 20 <br /> / TITLE General Manager DATE 11/11/05 <br /> i_____________________________ ___ _____ _________ _________________________ ______________________________________________ <br /> BILLING INFORMATIO_ . <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name ---Y-ST4'%1Ir-T�A! ': Address 2,a-Xq MaGcvo *4 Phone # 0,cg067-4aw <br /> C LpDsR Cn9S�-�i-o <br /> Signature \ vr - <br /> EH230038 <br /> (revised 1/31/02) <br /> i <br />