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SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL HEALTH DEPARTMENT
<br /> 304 E WEBER AVE,3RD FLOOR
<br /> STOCKTON,CA 95202
<br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT
<br /> THIS PERMIT EXRES 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 SITE # ; PROJECT CONTACT & TELEPHONE # Joe Bagley 367-4800
<br /> ' +--------------------------------------------------------------------------------------------------------------------------;
<br /> F ; FACILITY NAME San Joaquin Count Corporation Yard ; PHONE #468-3079 '
<br /> A ------------------------------------------y-----— -----------------------------------------------------
<br /> C 1 ADDRESS 1810 Hazelton Ave. Stockton, CA 95205
<br /> ,
<br /> , I +----------------------------------------------------------------------------------'-------------------------------------------;
<br /> L ; CROSS STREET Wilson Way
<br /> ' I +---------------------------- -------------------------------------------
<br /> T OWNER/OPERATOR PH�i #
<br /> $-
<br /> Y Dan McGann 3106
<br /> C ; CONTRACTOR NAME Bagley Enterprises, Inc. ; PHONE # 367-4800
<br /> 0 --------------------------�'---------P------------------------------------------------------------ -------------------------
<br /> N ; CONTRACTOR ADDRESS 2370 Maggio Cir,#4, Lodi 95240 ; CA LIC #774802 ; OLAssB,C-61(D21,D34,D40)
<br /> T +-------------------------------------------------------------------------------------- --------------------------------------,
<br /> R ; INSURER Monroe & Monroe Insurance ; WORK.COMP.# 1788626-2005
<br /> A ;--------------------------------------------- --------+-------------------------
<br /> C ; OTHER INFORMATION General-Liabilt� jp02-GL589707_____________
<br /> T +--------------------------- -- - - ---------+----------------------------------------;
<br /> 0 PHONE #
<br /> ' R +-----------------------------------------------------------------------------------+-
<br /> PHONE #
<br /> ----------------------------------------------------------------------------------------------
<br /> TANK ID # ; TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED
<br /> 39-
<br /> T ; 39-
<br /> 1 A ; 39-
<br /> N 1 39-
<br /> X ; 39-
<br /> 39-
<br /> 39- _
<br /> ;;;;;;;;;;;,,,,,,,,,,,,,,,,,,,,,,,,,,,,
<br /> P
<br /> L PPROVSD �APP.OVEDTH CONDITION(? DISAPPROVED
<br /> A I,1✓`1 � ` "�-' WITH CONDITIONS)N PLAN REVIEWERS _AMS DATE+ ,,,,,,,,,,,,,, �,, , ,,,,,,,,,,,,�,,,,,,�„ � � ,�,,,,,,,,,,,,,,,, ,,,,,,,,. ,,,,,,,, . ,
<br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF
<br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY
<br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO
<br /> BECOME SUBJECT TO WORKER'S COMPENSATZ LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE
<br /> FOLLOWING: "I CERTIFY THAT IN THE PERP CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO
<br /> WORKER'S COMPENSATION LAWS OF CALIFORNI .
<br /> r
<br /> APPLICANT'S SIGNATURE: TITLE General Manager DATE 12/8/05
<br /> �.-
<br /> BILLING INFORMATION: "' � Q
<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 Address Phone#
<br /> Signature
<br /> C-al-q e,&4 C"s 0--
<br /> EH230038
<br /> (revised 1/31/02) ✓ i' J �S� ;� T��-
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