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SAN JOAQUIN Environmental Health Department <br /> CC)iJIifY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 190 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT K UDC REPAIR/RETROFIT [] COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Joseph Bagley 209-3674800 <br /> A <br /> Facility Name San Joaquin County Fleet Svc - Corp Yard Phone # 2094684645 <br /> I <br /> L Address 1810 E Hazelton Ave , Stockton , CA <br /> TCross Street <br /> Y Owner/Operator County of San Joaquin Fleet Svc Phone # 2094684645 <br /> o Contractor Name Ba le Enter rises Inc Phone # 209-367-4800 <br /> T Contractor Address 2370 Maggio Cir #4 Lodi CA 95240 CA Lic # 774802 Class A <br /> A Insurer StarNet Ins Co/Berkeley Net Work Comp # BNUWC0136749 <br /> T ICC Technician's Name Michael Kennard Expiration Date 7/6/2023 <br /> R ICC Installer' s Name Michael Kennard Expiration Date 7/6/2023 <br /> Tank system work areaTank Size Chemicals Stored Currently Date UST <br /> (i.e. 67 piping sump, 91 leak detector, UDC 1 /2, e1c.) Installed <br /> T <br /> A Diesel (TA508122 ) 15 , 000 Diesel 1998 <br /> N <br /> K Gasoline (TA0508123) 15 , 000 Unleaded <br /> P ❑ ApprovedApproved with conditions ❑ Disapproved <br /> L a¢ Attachment With Conditions <br /> A / <br /> N Plan Reviewers Name Date / ) f <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: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOYANY 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." q <br /> Applicant's Signature — , A A. Title General Manager <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 /> SIGNATURE0� DATE 1I/% /7e) TiZ <br /> t <br /> 2of6 <br />