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SAN JOAQUIN nip44ITM D <br /> Environmental Heal4h fie artm <br /> COU NTY-- <br /> JUN 19 2U2U <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE , INDICATE PERMIT TYPE BELOW: DEPARTMENT <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> A <br /> C Facility Name Lodi Muni Service Center, City of Lodi Phone # 209-333-6800 <br /> 1 Address 1331 S . Ham Ln , Lodi <br /> L <br /> I Cross Street Kettleman Ln <br /> T <br /> Y Owner/Operator City of Lodi Phone # 209-333-6800 <br /> C Contractor Name Bagley Enterprises , Inc Phone # 209-367-4800 <br /> 0 <br /> N Contractor Address 2370 Maggio Cir #4 , Lodi CA Lic # 774802 Class A <br /> T <br /> R Insurer Work Comp # BNUWC0136749 <br /> A Berkeley Net <br /> C ICC Technician 's Name Expiration Date 2/24/2021 <br /> T Eric Molgaard <br /> 0 ICC Installer's Name Expiration Date 2/24/2021 <br /> R Eric Mol aard <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T 87 - Tank # 8 2 , 000 gal Unleaded 87 ) on file <br /> A 87 - Tank # 4 10 , 000 gal Unleaded ` on file <br /> N <br /> K <br /> P ❑ Approved KI Approved with conditions ❑ Disapproved <br /> L ` \ (See Attachment With Conditions) <br /> N Plan Reviewers Name � i� ivL� Date o ( Z- L) <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN 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 : "I 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 EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." O/e <br /> Applicant's Signature ��u �� ee Title W eF A`wiDate / � ` <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank . If the party designated below is different than the permit applicant, e . g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Joseph Bagley , Bagley Enterprises TITLE General Manager PHONE # 209-3674800 <br /> ADDRESS 2370 Maggio Cir #4 , Lodi Ca 95240 <br /> ' <br /> SIGNATURE f`'Y >�" DATE '/� 9�3 <br /> 2of6 <br />