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SANJOAQUIN Environmental Health Department <br /> CC) UN I Y <br /> APPLICATION FOR UNDERGROUND STORAGE TANK JAN 3 12019 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Joseph Bagley 209 -3674800 <br /> Facility Name Tracy Unified School District Phone # 209 -830-3200 <br /> Address 1975 W Lowell Ave , Tracy , CA 95376 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Tracy Unified School District Phone # 209-830-3200 <br /> C Contractor NamePhone # <br /> o Ba le Enterprises , Inc 209-367-4800 <br /> T Contractor Address 2370 Maggio Cir #4 Lodi CA 95240 CA Lic # 774802 Class A <br /> R <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC0136749 <br /> T ICC Technician 's Name Eric Molgaard Expiration Date 2/25/2019 <br /> R ICC Installer' s Name Eric Molgaard Expiration Date 2/25/2019 <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 <br /> Regular/Unleaded TA0252102 10 , 000 1991 <br /> A Diesel (TA0252101 ) 10 , 000 1991 <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (SeNAachment With Conditions ) <br /> A <br /> N Plan Reviewers Name Pe�� ,, ,,,,� r Y \"" � Date <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." / cov- z�%n Mat <br /> Applicant's Signature " Title T71Az-y UK)0W i Sc 04� OLIZV`Date <br /> V, <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 /> SIGNATURE . DATE <br /> 2of6 ORIGINAL <br />