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0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3"D FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK RETROFIT -PIPING REPAIRIRETROFIT -UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />----------------------------------------------------------------------------------------------------------------------------------- <br />EPA SITE # ; PROJECT CONTACT & TELEPHONE # Joe Bagley 209-367-4800 <br />---------------------------------------I <br />D6 w--ri- U& w -h- - Ga- Ed -g-e- <br />F : FACILITY NAME PHONE # 468-3106 <br />A------------------------------------------------------------------------------------------------------------------------------ <br />C : ADDRESS - 121 S. San Joaquin_ St- --- <br />. Stockton 95202 <br />I------------ ------------- ----------------------------------------------------------- <br />1 L : CROSS STREET <br />I------------------------------------------------------------------------------------------------------------------------------ <br />T <br />Y OWNER/OPERATOR S, J. County Public Works (Dan McCann (Flt Mgr)� PHONE # 468-3106 <br />--------------------------------------------------------------------------------------------------------------------------------- <br />C : CONTRACTOR NAME Bagley Enterprise , : PHONE # <br />0 s 367-4800 <br />N 1 CONTRACTOR ADDRESS 2370 ---Maggio Circle #4 CA LIC # 774802 1 CLAS5B, C61 (D21 D34,,.D40) <br />T------------------------------------------------------------------------------------------------------------------------ <br />R : INSURER Monroe & Monroe Insurance � WORK.COMP.# 1788626-2005 <br />A1 ----------------------------------------------------------------------------------------------------------------------------- 1 <br />C : OTHER INFORMATION General Liabilitv 1/02-GL589707 <br />T------------------------------------------- ---------------------------------------------------------------------------------- <br />0 : : PHONE # <br />R------------------------------------------------------------------------------------------------------------------------------ <br />: PHONE # <br />---------------------------------------------------------------------------------------------- <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />P <br />L APPROVED ✓ APPROVED WITH CONDITION(S) DISAPPROVED <br />A 1 (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS7A7 E Wz DATE 06-24-9 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALI IA." <br />APPLICANT'S SIGNATURE: TITLE General Manager DATE <br />----------------------------------- ------------ -------------------------------------------------------------------- <br />(1/ <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br />coverage per tank. If the party designated below is different than the permit applicant, e.g. properh., <br />j <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />a =-Z <br />Signature, <br />EH230038 <br />(revised 1/31/02) <br />Address Phone # <br />