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0 <br />ENVIRONMENTAL HEALTH DetARTMENT <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 />OPIPING REF AIRIRETROFIT ❑UDC REPAIR/RETROFIT <br />BILLING INFORMATION: <br />Indicate the responsible IiA to be billed for additional EHD staff time expended beyond permit payment coverage per tank If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME Joseph Bagley TITLE President PHONE# 367-4800 <br />2370 Maggio Circl), Ste 4, Lodi <br />SIGNA <br />EH230038 (revised 8/8106) <br />1 <br />4( <br />TANK RETROFIT <br />F <br />EPA Site # Project Contact & Telephone # Joe Bagley 367-4800 <br />C <br />Facil-ItyName SJC Sheriff's Operations #2 (Fmergency Gen -Jail <br />Phone#468-4637 <br />I <br />Address 70W N. Micheal N. Canlis Blvd, French Camp <br />L <br />T <br />Cross street Mathews Road <br />Y <br />Owner/Operator SJC Facilities nte <br />#468-4637 <br />c <br />-Manageme <br />Contractor Name Joseph Bagley <br />ne # 367-4800 <br />0 <br />T <br />Contractor Address 2370 Maggio Circle SClash C D21R <br />InsurerMonroe @ Monroe Insurancek Comp #1788626-2006 <br />A <br />C <br />T <br />ICC Technician's Certification NumberO <br />iration Date <br />ICG installer's Certification Number 52469$$ <br />- Uliration <br />Date 1125 I08 <br />R <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />OApproved proved with conditions ❑Disapproved <br />P <br />L <br />(S Attachment With Conditions) <br />A <br />2-"10-0-7 <br />� <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />JOAQUIN COUNTY, ENVIRONMJ�R�H DEPARTMENT. <br />PERFORMANCE OF THE WICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />"I <br />THE CERTIFY <br />WORKF_R'S COMPENSATION LFORNIA." CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING- <br />THAT IN THE PERFORMANCE FOR WHICH THIS MIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNA." <br />Contractor _ Dale 2112107 <br />BILLING INFORMATION: <br />Indicate the responsible IiA to be billed for additional EHD staff time expended beyond permit payment coverage per tank If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME Joseph Bagley TITLE President PHONE# 367-4800 <br />2370 Maggio Circl), Ste 4, Lodi <br />SIGNA <br />EH230038 (revised 8/8106) <br />1 <br />4( <br />