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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SANJOAQMCOUNTY <br /> 600 East Main Street,Stoebten,Cafifernia <br /> Telephone: (2 09) 2 :( )468-3433 <br /> APPUCATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING1 I <br /> n THIS PERMIT EXPIRES 180 DAYS THE W: <br /> APPROVAL DATE. INDICATE PERMIT TYPE BELOW <br /> DTANK RETROFrr []PIPING REPAIRA moFrr ®UDC REPAIRRETROFIT ElcoLDSTART/EVR UPGRADE <br /> F EPA Site# -34 Projed contact&Telephone#jo, 209-367-4800 <br /> C Facility Name SJC Sheriff's Fueling Operations Phone# 209-468=4645 <br /> 1 Address 7000 Michael Canlis Blvd French gauIp 95231 <br /> L <br /> I Cross Street W. Mathews Rd. <br /> T Phone <br /> Y owner/operator SJC — Fleet Services Motor Pool( McCann) 209-468-3098 <br /> C Contractor Name le Enterprises, Inc. Phone 209-367-4800 <br /> NCorrtractor Address 2370 Maggio Circle,#4 95240", CA Lic#774802 CiasSB,C-61(D21,D 1D4 <br /> T <br /> R .Insurer Monroe -&--Monroe -_.General Liabilit Insurance k Comp 4519701 <br /> C ICC Technician'sC 'on Number 5248576-E1 Expiration 6/7/09 <br /> T <br /> OICG I let's Certification Number Expl on <br /> Diate <br /> R <br /> micals StDred <br /> Tank ID Tank Size Che currenny/Previousiy Date UST Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved DApproved with conditions ❑Disc oved <br /> L (See Aftachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAP!JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 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" CONTRACTOR'S 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 EMPLOYPERSONSSUBJECT TOWORKER'S COMPENSATION LAWS <br /> OF CALIFfRN Y, <br /> Applicants Signature T fete <br /> BILUG INFORMATION: <br /> 61 <br /> Indicate the responsible party to be billed for additionalEHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit appG t, a-g- property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Joseoh® BaeleyGeneral NgpMer PHONE A 209-367-4 <br /> ADDREss 2370 Maggio Circle, Unit 4, Lodi, CA 95240 <br /> SIGNATURE <br /> EH (revised 12/31104-/ <br /> 1 <br />