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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 /> )RITANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F \EPA Site# Project Contact&Telephone# 209.367.4800 <br /> A <br /> C Facility Name Sheriffs Operations Ctr#2-San Joaquin County Phone# 209.468.4616 <br /> 1 Address 7000 N Michael Canlis Blvd French Camp CA 95231 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Anthony Hagarty or Brian Beckman Phone# 209.468.5217 <br /> C Contractor Name Bagley Enterprises, Inc Phone# 209.367.4800 <br /> 0 <br /> N Contractor Address 2370 Maggio Cir#4 Lodi, CA 95240 CA Lic# 774802 Class A <br /> T <br /> AInsurer Insurance of the West Work Comp# WSD507145901 <br /> T 9 p�aard Expiration ICC Technician's Name Eric Mol ration Date 7/6/2025 <br /> T <br /> R ICC Installer's Name Eric Molgaard Expiration Date 7/24/2025 <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 Dsl Tank ID TA0504968/10182105-001 20,000 1989 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L e-Attachment With Conditions) <br /> A i N Plan Reviewers Nam Date <br /> APPLICANT MUST PERFORM ALL WORK(N ACOORDANCE 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 .cl//L/�i .cYLl�Le:C.{l/L Title Admin Date 12/17/2024 <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 /> NAME—Bagley Enterprises,Inc TITLE_Admin PHONE#_209.367.4800 <br /> ADDRESS_2370 Maggio Ciirrj#44 Lodi CA 9552/40s <br /> SIGNATURE �)to, /'�'Tti�1zL, .c ddAG 4, DATE 12/17/2024 <br /> 2of6 <br />