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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue, it Floor,Stockton,California 95202 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> L1 TI FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW <br /> ®TANK RETROFIT PPIPING REPAIRMMOFIT ®UDC REPAIR1RETROFrr <br /> F EPA Site# ;onw&Telephone# <br /> A <br /> C Facility Name Sheriff's Operations T-Phone#468-4645 <br /> 1 - <br /> L Address 7000 Michael Canlis Road, French Camp <br /> I CrossStreet Mathews Road <br /> T <br /> Y Ownedoperator San Joaquin County (Dan McGann Fleet Mgr) Phone#468-3106 <br /> 0 <br /> C Contractor Name Jose Ba le Phone <br /> #367-4800 <br /> N <br /> T ContraciorAddress 2370 Maggio Circle, Ste 4 cAuc#774802 ciassB,Cl(D21,D34:D40) <br /> R <br /> A Insurer Monroe & Monroe Insurance work comp,#1788626-2005 <br /> C <br /> T [CC Techniclarfs Cerfilication Number Expiration Date I <br /> R ICC Installer's Cerffk*ffion Number 5246988-U1)t 5252219-U1 Expiration Date 1/25/07 j-2:5- 7 <br /> Chemicals Stored <br /> Tank ID# Tank Size Currently/Previously Date UST installed <br /> T <br /> A <br /> N <br /> K <br /> P ElApproved Approved with conditions FIDisapproved <br /> L (See 9j. Conditions) <br /> A <br /> N Plan Reviewers Name--W- WA 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 AGENTS SIGNATURE CER71FIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WQW FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> HIRING OR SUBCONTRAC77NG SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFOR CE OF FOR ICH MIT IS ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAOF FOR <br /> WS <br /> Contractor Daft <br /> ILLING INFORLOIATIO N: <br /> Indicate the responsible party to be billed fbr additional EH D staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is dillarent than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date Wow. <br /> NAMEJos6pb Bagley TITLE President PHONE# 367-4800 <br /> ADDRESS 2370 Maggio,,,Cirle, Ste 4, LdN, CA 95240 <br /> SIGNATURE_, <br /> ESH4230038 818/06 <br />