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SANJOAQUIN Environmental Health Department <br /> _ _ . - COUNTY _ _ _. <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 # Joseph Bagley, 209-367-4800 <br /> A <br /> Facility Name City of Lodi Phone # 209-269-4923 <br /> I Address <br /> � 1331 S Ham Lane , Lodi , 95242 <br /> TCross Street Kettleman <br /> Y Owner/Operator Matt Sinclair Phone # 209-2694923 <br /> C Contractor Name Bagley Enterprises , Inc Phone # 209-367-4800 <br /> 0 <br /> N Contractor Address Maggio T 2370 Ma io Cir #4 , Lodi , Ca 95240 CA Lic # 774802 Class A B , HAZ C-61 <br /> R Insurer Work Com # <br /> A Insurance Company of the West p WSD507145901 <br /> TICC Technician 's Name Expiration Date <br /> R ICC Installer' s Name Michael Kennard ICC # 5254811 Expiration Date 08/ 15/2025 <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 Gasoline Dispensing 10 , 000 gal Unleaded Fuel 1989 <br /> A Diesel Dispensing 5 , 000 gal Diesel 1989 <br /> N <br /> K Gasoline Dispensing 2 , 000 gal Unleaded 1989 <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 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." <br /> Applicant's Signature Title Contractor Date 6/27/2024 <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 /> NAMEJoseph Bagley for Bagley Enterprises , ffE General Manager PHONE # 209-3674800 <br /> ADDRESS 2370 Maggio Cir #4 , Lodi , Ca 95240 <br /> SIGNATURE��� DATE 6/27/2024 <br /> 2of6 <br />