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SANJOAQUIN Environmental Health Department <br /> - COUNTY <br /> - <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMITTYPE BELOW: <br /> ❑ TANK 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 City of Lodi Phone # 209.333.6800 <br /> I Address <br /> L 1331 S. Ham Lane, Lodi CA 95242 <br /> TCross Street Kettleman <br /> Y Owner/Operator City of Lodi/ Matt Sinclair Phone # 209.269.4923 <br /> c Contractor Name Phone # <br /> o Bagley Enterprises, Inc 209.367.4800 <br /> T Contractor Address 2370 Maggio Cir#4, Lodi CA 95240 CA Lic # 774802 Class A <br /> R Insurer Work Comp # <br /> A Insurance of the West p WSD507145902 <br /> c ICC Technician's Name Expiration Date <br /> T Nikola Zagorov p 2/27/2027 <br /> orov <br /> ICC Installer's Name Nikola Za Expiration Date <br /> R g p 5/23/2027 <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 Spill containment 2,000 Unleaded 1989 <br /> A <br /> N <br /> K <br /> P 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 General Manager Date 9/22/2025 <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, Joseph Bagley TITLE General Manager PHONE #209.329.0582 <br /> ADDRESS n 2370 Maggio Cir#4 Lodi, CA 95240 <br /> SIGNATURE Qdd¢ G fa,924 y DATE 9/10/2025 <br /> V el <br /> 3of6 <br />