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• SAN JOAQUIN COUNTY 11 ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3RD FLOOR STOCKTON, CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: _TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +--------------------------------------------------------------------------- - t±------------- ----------+ EPA SITE # ; PROJECT CONTACT & TELEPHONE # JOE'- Bagley (209)367-4800 ------------- --------------------- --------------- ------ +________________________ ; -PHONE # 468-2068 ' F ; FACILITY NAME Downtovm Garage A+---------------��++--------------------------------------------------------------- ---------------------------------- C ; ADDRESS_121_x2.__San__Joaquin_St,_--------- to-ckton_R5202______________ L ; CROSS STREET I+-------------------------------------------------------------------------------------------------------------------I i Y OWNER/OPERATOR S. J. County Public Works (Dan McCann (Flt Mgr) PHONE # 468-3106 ---+-----------------------------------------------------------------------------------+--------- -- -- -- -- C I CONTRACTOR NAME Bagley Enterprises, Inc. ; PHONE # 367-4800 0 +---------------------- - ----------------------------------------------------------------------- i N ; CONTRACTOR ADDRESS 2370 Ma to Cir. #4 Lodi 95240 - CA LIC -#-774802 _ ��sB�C61(DA,I D34,D40) T-------------------------- -----g -------------- ----- - - R INSURERMonroe & Monroe Insurance ; WORK.0°MP.#1788626-2005 A C OTHER INFORMATIONGen Liability_ #02 GL589707 ' T+---------------------------------- ---- ----------------------------------+---------------------------------------- O PHONE # PHONE # ---------------------------------------------------------------------------------------------- TANK ID # TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- T ; 39- A 39- N 39- K 39- 39- 39- P L ; �VED APPROVED WITH CONDITION(S)-kl DISAPPROVED A (SES ATTACHMENT WITH CONDITIONS) �A_ �f. :_N_: PLAN REVIEWERS NAME DATE APPLICANT MUST PERFO WORK IN ACC D TH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE:4!6 TITLE General Manager DATE J +------------------------------------------------------------------------------- ---------- --------- BILLING INFORMATION:y) (��G��o•JS c Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name Address Signature EH230038 (revised 1/31/02) 1 Phone #