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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) 458-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE W.. <br />INDICATE PERMIT TYPE BELOW. <br />c <br />TANK RETROFIT NPIPING REPAIR�RETROFrr nI ItN_ RFPA1PMP7Pn1=IT <br />F <br />EPA Site # <br />Project Contact & Telephone #Joe Bagley 367-4800 <br />A <br />C <br />Facility Name San Joaquin County Jail Facility <br />Phone# 468-4637 Tom <br />L <br />Address 7000 N. Micheal N. Canlis Blvd French Cam <br />1 <br />T <br />Cross Street Mathews Road <br />Y <br />Owner/Operator Facilities Management <br />Phone# 468-3357 <br />Q <br />Contractor Name Joseph Bagley <br />Phone# 367-4800 <br />T <br />Contractor Address 2370 Maggio Circle, Ste 4, Lodi9524 CAuc#774802 ClassB,C-61(D21,D <br />A <br />Insurer Monroe & Monroe <br />work Comp # 1788626-06 <br />T <br />ICC Technician's Certification Number N/A <br />Expiration Date <br />R <br />ICC Installer's Certification Number <br />Expiration Date 1/25/05 & 1/25/077 <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 />P <br />ElApproved roved with conditions ❑Disapproved <br />L <br />( Attachment With Conditions) <br />A <br />N <br />�✓� <br />Plan Reviewers Name�� J Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAVH AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br />THAT IN THE PERFORMANCE OF TH WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA" , ) <br />AWsignawre T,de Contri{Cor [>ate 11/9/06 <br />BILLING INFORMATION: <br />Indicate the responsible party 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 Circle,'Ste 4, Lodi, CA 95240 <br />EH230038 (revue 8/8/06) <br />1 <br />t, D40 <br />