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SAN JOAQUIN Environ GalEVED <br /> COUNTY <br /> OCT ' 1 3 2021 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMARONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE , INDICATE PERMIT TYPE BEL(U. PARTMENT <br /> 91 TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/F.VR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Joe Bagley 209-367-4800 <br /> APhone # <br /> Facility Name Tracy Unified School District 209-830-3230 <br /> I <br /> L Address 1975 W Lowell , Tracy Ca 95376 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Lisa Sawyer Phone # 209-830-3216 <br /> C Contractor Name Phone # 209-367-4800 <br /> Q Bagley Enterprises , Inc <br /> N Contractor Address CA Lic # 774802 Class A B HAZ C-61 <br /> T 2370 Maggio Cir #4 Lodi CA 95240 <br /> R <br /> A Insurer StarNet Insurance Co Work Comp # BNUWC013674921 <br /> C ICC Technician 's Name Expiration Date 11 / 12/2022 <br /> T Andrew Bagley <br /> Q <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i .e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T Drop I- Ibe on Unleaded /87 Tank 10 , 000 ga Unleaded/87 6/7/1991 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date 1 G — I 7 - 20/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." <br /> Applicant's Signature L02eIL 13 Title General Manager Date 9/30/2021 Revised 10/13/2021 <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 Bagley Enterprises , Joe Bagley TITLE General Manager PHONE # 209- 3674800 <br /> ADDRESS 2370 Maggio Cir #4 , Lodi CA 95240 <br /> joseph13aD �' DATE 9/30/2021 Revised <br /> SIGNATURE 021 <br /> 2 of 6 <br />