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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3'FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ----y <br /> _______________________________-------------------------------------------------- <br /> 1 EPA SITE # 1 PROJECT CONTACT A TELEPHONE # ��- ,^ .IG 7 I.OM___________________( <br /> ______Joe -- �it3MJ <br /> ONE <br /> F FACILITY NAME Tracy_Unified_School-_District-Motor_Pool---______I '___$31-5051__________________; <br /> 1 A + —- - <br /> 1 c 1 Am--ss <br /> I + 19-75W. Lowell-Ayeuixe__ _______Tracy,_CA-9.5275_---------------------------------------------------1 <br /> L CROSS ETR--T <br /> i I +_________________ _______________________________________________ <br /> I PHONE # I <br /> Yi 'rracy`Tnlfied School District1 831-5051 <br /> --+----------------------------------------1 <br /> I C 1 CONTRACTOR NAME Bagley I]Tterprises;_ Inc.-------------------------------- PHONE # 367-4$00 1 <br /> ______________________________________ I <br /> 1 O +________________ __ 9-g. ' ' CA LIC # <br /> I N 1 CONTRACTOR ADOREss 2370 Maggio Cir, #4 Lodi 95240 : __ ___ _ 774802 c�bB� C6l(D21_LD3/4�W) <br /> --- - ------------------------------------------------- ------------------- <br /> i R i INSURER Monroe @ Monroe Insurance 1 rAxx co.,e ®1788626-2005 _______; <br /> - ------ -----------------------------------}- <br /> I c i OTHER INFoRMATIoNGeneral Liability #02-GL589707 1 1 <br /> ---------------------------+---------------------------------------- <br /> 11 <br /> T }--'---------------------------------------------o ' ' PHONE # ' <br /> PRONE # <br /> __________ <br /> ________________ <br /> i1TANR ZD11# TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY i DATE OST INHTALLSD <br /> 39- <br /> 1 T 1 39- <br /> I A 1 39- <br /> 39- <br /> 39- <br /> 39- <br /> 1 39- <br /> N 111111,H 11„11111,111111111111., '111111111111111111111111 L „X11111111 L'1,,,,,,,., ,. �.��,,,,•,,,, <br /> I P 1 <br /> 1 L 1 APPROVED / _'APPROVED WITH CONDITION(S) DISAPPROVED" <br /> 1 A 1 IS B ATTACHMENT WITH CONDITIONS) <br /> N I PLAN REVIEWERS NAME �u- NG DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND RHOULATZONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY <br /> THAT IN TEE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S SATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATOR. CERTIFIES THE <br /> FOLLOWING: •I CERTIFY THAT IN THH FORNANCH OF THE WORK FOR CH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFO IA.- <br /> 1 APPLICANT'S SIGNATURE: TITLE General Manager DATE 11/11/05 <br /> 1 <br /> + _____ __________ ____________________________________________ ________ + <br /> BILLING INFORMATION. <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name -ZgM*4* %A,-%ACP-- Address onA-Gc-oo Phone# eag3367-4'80e <br /> Signature <br /> - <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />