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ENVIRONMENTAL HEALTH DEPART <br /> SAN JOAQUIN COUNTY 'RbEIVED <br /> 600 East Main Street, Stockton, California 95202 DEC 02 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 2��4 <br /> APPLICATION FOR UNDERGROUND STORAGE TANg�NVIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT 9 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A San Joaquin Cc Fleet Sheriffs Ops 209-468-4645 <br /> � Facility Name q P Phone# <br /> I ress Add <br /> L 7000 M6chae,LCa.v►Lf,k31vcL FreqdyCo 4p, C,4 <br /> TCross Street <br /> Y Owner/Operator San Joaquin County Fleet Svc Phone# <br /> C <br /> 0 Contractor Name BaV ey EvtterprUe4; Inc,. Phone# 209-367-4800 <br /> N Contractor Address 2370 M CLr, St�4, Lod,, 95240 CA Lic# 774802 <br /> T a.�-ie- Class 3, D21,D34, 40 <br /> A Insurer StateiCotnp InkFu*td Work Comp# 730-0000558 <br /> T ICC Technician's Name Eric Molgaard Expiration Date 02/12/2015 <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> 1IR Z5.o00 <br /> A <br /> N <br /> K <br /> P ❑ App ved AQeeA <br /> pproved with conditions Disapproved <br /> 4�( chment With Conditions) <br /> A I�N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JO QUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER R 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 <br /> TO WORKER'S COMPENSATIoV <br /> LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE F THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." �y,,� �� 4Zrd <br /> )'- <br /> ✓' — <br /> Applicant's Signature Aeg Title S9-441-=,E.A; Date 2- .0 ZZ- <br /> -C7 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> NAMEjo�111BOg eiy, 3a.le-y Enterpr6y-k, bnE Cie l"cLt,Ma*Laqr PHONE# 209-367-4800 <br /> ADDRESS2370 Malgi&Cir, Ste,4, Lodi, CA 95240 <br /> SIGNATURE DATE 0�alQIJ ZJe:+ y:� <br /> EH230038(revised 07/2 0) <br /> 2 <br />