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SANJOAQUIN Environmental Health Department <br /> COU NTY --- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <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 # Joe Bagley 209-3674800 <br /> A <br /> C Facility Name San Joaquin General Hospital Phone # 209-468-7063 <br /> I Address 500 W Hospital Wy, French Camp <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Jesse Escotto Phone # 209468-7063 <br /> C Contractor NamePhone # 209-367-4800 <br /> o Bagle 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 /> ICC Technician ' s Name Expiration Date 11 / 12/2022 <br /> T Andrew Bagley <br /> ICC Installer's Name P <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> TDrop T , be101000. ga 9/1 /1995 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L e Attachment With Conditions) <br /> A <br /> N 7i/ <br /> Plan Reviewers Name _ Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCOR CE 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 Title General Manager Date 9/9/2021 <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 # 209-367 -4800 <br /> ADDRESS 2370 Maggio Cir #4 , Lodi CA 95240 <br /> SIGNATURE 06 -haDATE 9/9/2021 <br /> 2of6 <br />