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SANJ O W I Env[ronmental Health Deparfr'nen# <br /> 0 U N T Y <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 100 DAYS FROM THE APPROVAL DATE. INDICA7E PERMIT TYPE BELOW. <br /> FANK RETROFIT ❑PJPING REPAIRJIRETROFIT ❑UDC REPAIRJRETROPIT 0 COLD STARTMVR UPGRADE <br /> F EPA Site# Project Conrad&Telephone A Joseph Bagley 209-367-4800 <br /> c Facility Name Ban Joaquin County Fleet Svc-Sheriffs Ops 91 Phone# 209-469-4646 <br /> I <br /> L Address 7000 Michael Canlis Blvd, French Camp <br /> 7 Cross street <br /> Y OwrlerlOperatar County of San Joaquin Fleet Svc Phone# 209-498-4645 <br /> o Contractor Marna Bacilley Enter rises Inc Phone u 209-367-4800 <br /> T Gontractor Addreaa 2370 N1a io Cir#4 Loth CA 95740 CA Llc J 774802 Class A <br /> A Insurer insurance of#11 West MFk Comp 0 WSD5071459a1 <br /> iIC Technician's Name Expirawn pate <br /> 'R Ice Installers Name <br /> ft EriC Nl019a0jrd t=xpiral-on Date 7Jr241=$ <br /> Tank system work area rank Size Chemicals Stored Currenily Date UST <br /> ¢...ar p04 ruff,;,OY Ioak d46ldw.UDC M4 CV4 lWalled <br /> T 87 Octane 2fi3Ot]0 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with canditlons ❑ Dlsappra►+ed <br /> L eAllachmem Wife Cor`:ditions) <br /> M Plan Re�+i914AfS Narrl � , )"z'�V'711' <br /> dale 10 ` <br /> PPLICANT MWT PHRF4RM ALL M IN ACCORDANCE VIATH S.AH XMQUIN COUNTY ORDINANCES. STAtr LAM.Awd gULES AND REdULATrONS CC SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL EALTH DEPARTMENT_OWNER OR LICENSED AGENTS 51GNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> TH F PERFORMANCE OP THE MRK FOR MIC H THIS PERMIT IS 18 S UED.I SI iALL NOT EMPLOY ANY PERSON IN SUGH A MANNER AS TO BECOME SUBJECT TO <br /> WORiet-WS COMPENSATION LAWS OF CAUFORKLA" CONTRACTOR'S tIJRING OR SuBGaNTRACTING 3I0H?sTuRE CERTIRES THE POLLOVANO. "I GI`RWY <br /> THAT IN THE PERFQRMANCE OF THE WORK FOR V IICH THIS PERMIT IS ISSUED.1 SHAtL EMPLOY PERSONS SUBJECT TO ViCOKER'S COrAPENSATION LAWS <br /> OF CAUirDRNIF" <br /> 4Awkearnrs srdrulure t rt L x c� 7t,18 Ofc Manger osae 91512024 <br /> BILLING INFORMATION: <br /> Indicate the responsible patty to be Billed for additional EHD staff time expended beyond permit payment CDVBFage pef <br /> tank. If the pilr#y designated below is different than the permit applicant, e_g_ proparty owner, The party must <br /> acknowledge this fesponslbility For the billing byelgnature and date below. <br /> NAMEADO Marie Ad die r. Bagley Enty(nriSe9 TITLE Ofc FNana0r ADDAESS PHONE tk 209-367-4800 <br /> 2370 Mappic Cir#4. Lodi,CA 95240 <br /> SIGNATURE DATE 91512024-- <br /> a nr[3 <br />