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64 NTAL HEALTH DEPARTMENT <br /> JAN '2 0 2009 SAN JOAQUIN COUNTY <br /> ENVIRONMENT HEAWEast Main Street,Stockton,California 95202 <br /> PERMIT/SERVICF-&Iephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> �7 <br /> THIS PERMIT EXPIRES 190 DAYS FROM THE APPROVAA-LII DATE. INDICATE PERMIT TYPE BELOW <br /> UTANK RETROFIT ®PIPING REPAIRIRETROFIT LJUDC REPAIR/RETROPT 1- COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Joe Ba le 329-0582 <br /> A <br /> C Facility Name MoraFast—N—Eaay #60 Phone# —6194 <br /> IL Address 10878 N. HW 99 Frontage Road, Stockton <br /> T cross street Eight Mile Road <br /> Y Owner/operator Shawn Corporation Phone# 707-747-2955 <br /> oContractor Name Joseph Bagley Phone 367-4800 <br /> 0 <br /> T Contractor Address 2370 Maggio Circle .#4 Lodi 95240 CALic#774802 ClassB C61(D21,D34,D4( <br /> R I Insurer Monroe & Monroe General Liability work Comp#Wr±N004519701 <br /> T ICC Technician's Certification Number 8014628—UT Expiration Date Nov 11, 2010 <br /> R ICC Installer's Certification Number 8014620 - U1 Expiration Date Jul 3( , 2010 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved / <br /> A proved with conditions []Disapproved <br /> L (See Attachment VIM Conditions) <br /> N Plan Reviewers Name Date 112 IZ2 It <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WTM SAN JOAQUIN OOUNTY 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 COMPENSATION LAWS OF CALIFORNIA" CONTRACTORS 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 /> Appikants Sigreture TNe Contractor Date n�I�3�C'`/ <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 Joseph Bagley TITLE President PHONE# 367-4800 <br /> ADDRES5370 Maggio Circle, #4, Lodi, CA 95240 <br /> SIGNATURE <br /> EH230038(revised 12/31/04 <br /> 1 <br />