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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 /> V4ANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Joseph Bagley 209-367-4800 <br /> C Facility Name San Joaquin County Fleet Svc-Sheriffs Ops#1 Phone# 209-468-4645 <br /> 1 Address 7000 Michael Canlis Blvd,French Camp <br /> TCross Street <br /> Y Owner/Operator County of San Joaquin Fleet Svc Phone# 209468-4645 <br /> o Contractor Name ga le Enter rises, Inc Phone# 209-367-4800 <br /> N Contractor Address 2370 Maqqio Cir#4, Lodi CA 95240 CA Lic# 774802 Class A <br /> A Insurer Insurance of the West Work Comp# WSD507145901 <br /> ICC Technician's Name Expiration Date <br /> R ICC Installer's Name Eric Molgaard I Expiration Date 7/24/2025 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 ptping sump,91 leak detector,UDC 1n.etc.) Installed <br /> T 87 Octane 25,000 <br /> A <br /> N — — <br /> K <br /> I <br /> I <br /> P ❑ Approved P Approved with conditions ❑ Disapproved <br /> I (See Attachment With Conditions) <br /> A = — <br /> N Plan Reviewers Nam � v_ pi►"s-- Date 0J 2o I <br /> APPLICANT MUST PERFORM ALL WO F�K IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL IIIIIIiiiiilEALTH 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 SUBJECTTO <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 /> plicant'e Signature ^'K �Y Tice — — Ofc Manger Date 9/5/2024 <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 /> NA"p:Ann Marie Addler, Bagley Enterprises TITLE Ofc Manager AnnRFRR PHONE# 209-367-4800 <br /> 2370 Maggio Cir#4,Lodi CA 95240 <br /> SIGNATURE ----_ —DATE —9/5/2024- <br /> 2 of 6 <br />