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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW <br /> DTANK RETROFIT 11PIPING REPAIR/RETROFIT E]uDc REPAjRmETRoFrr <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> c Facility Name Sherif f I s Operations Fueling Facility P e#468-4645 <br /> L Address 7000 Michael Canlis Road, French Cam p, 95231 <br /> ICrossSheet Mathew Road <br /> T <br /> Y Owner/OPerator San Joaquin County (Dan McCann Fleet Mgr) Phone#468-3106 <br /> C <br /> 0 Contractor Name Joseph Ba le PhOne#367-4800 <br /> N <br /> T or Add 2370 Maggio Circle, Ste 4 CA uc#774802 Gla ssB,Cl(D21,D34 D40: <br /> R <br /> A insurer Monroe & Monroe Insurance work Comp#1788626-2005 <br /> C <br /> T ICC TechnicianscertilicationNumber 5261103-UT Expiration Date 6/28/07 <br /> 0 <br /> ICC Installer's Cerfification Number 5246988-U1 & 5252219-UI Expiration Date 1/25/07 (Both) <br /> Tank ID# Tank Size Chemicals Stored sty Date UST Installed <br /> CurrentlytPreviou <br /> T <br /> A <br /> N <br /> K <br /> P DApproved N"oved with conditions ElDisapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N <br /> Plan Reviewers Name Date <br /> 7 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JO 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 /> WORKERS COMPENSATION-OV416 OF CALIF IA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE 091THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKEWS COMPENSATION LAWS <br /> OF CALIFORNIA-" <br /> APPfic-ft Sv-k� roe Contractor Deft 71d-d6 C <br /> — / fr �BILLING INF TION: <br /> Indicate the responimtr/party to be billed for additional END staff time expended beyond permit payment coverage per tank- If <br /> the party designated below is difilarent than the permit applicant e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by.signature and date Wow. <br /> NAMEJosd-pla Bagley TITLE President ---__pHoNE# 367-4800 <br /> ADDRESS -� <br /> 2370 Maggioirle, Ste 4, Lodi, <br /> A 95240 <br /> SIGNATURE <br /> EH 3E(revised <br />