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❑ New Facility )e Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name San Joaquin County Sheriffs Ops #1 Site Address 7000 n Michael Canlis Blvd city French Camp State CA zip 95231 APN Supervisor District Type of Service ❑Application for ❑Consultation ❑Change of Owner 0 Repairs or ❑Other Requested Operating Permit Remodel Comments Bagley Enterprises is contracted with San Joaquin County to repair primary fuel leak in underground storage tank Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect required ❑Billing Party Nacility Owner PIPcility Contact ❑Property Owner ❑Contractor ❑Architect FirstNameSan Joaquin County Last name Kimberly Harris If contractor,indicate type and license number Address P O Box 1810 city Stockton State CA ZIP 95201 Phone Phone Email kmharris@sjgov.org 209.953,7508 Billi7qlyng Party ❑Facility Owner ❑Facility Contact ❑Property Owner Contractor ❑Architect First Name Bagley Enterprises Last name If contractor,indicate type and license number A-774802 Address 2370 Maggio Cir#4 city Lodi State CA zip 95240 Phone 209.367.4800 Phone Email joe@bagleyenterprises.com sales@bagleyenterprises.com ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect First Name Last name If contractor,indicate typAd license number YML— Address City State tw4CO Phone Phone Email } BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge-t @�dvVi kl�p�ect specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my busi71rs9� /iQ i _vVNT�� form. TEE_ I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codesr Standards,STATE and FEDERAL lavy{s.APPLICANT'S SIGNATURE: ILfL�� xdr'l� , DATE: _09/05/2024, ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT_Contractor Title If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Ater t3y+ .�� Asslgrted 70 � e4f JUked FA ID DiG ] PJ< � F� Rv ord Nuns r "� rrff r Rev 06/12/2024 If f