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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 /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Jose h Ba ley 209-367-4800 <br /> � Facility Name San Joaquin Regional Transit District (RTD) Phone# 209-467-6672 <br /> � <br /> Address 2849 E. Myrtle St Stockton CA 95205 <br /> T Cross Street <br /> Filbert <br /> Y owner/operator Darla Smith Phone# 209-467-6672 <br /> C Contractor Name Ba le Enter rises Inc Phone# 209-367-4800 <br /> N <br /> T Contractor AddressMaggio CA 95240 CA Lic# 748o2 Class A R HAZ _ <br /> 61 <br /> R Insurer <br /> A Midwest Employers Casualty Company Work Comp# BNUWC0136749 <br /> T ICC Technician's Name Expiration Date <br /> T Eric Mol aard P� 2019 <br /> ' <br /> R ICC Installers Name <br /> R Eric Mol aard Expiration Date 2018 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> y <br /> (i.e.87 piping sump,91 leak detector.UDC 1/2,etc.) Installed <br /> T Diesel Transition Sump 40,000 ql #2 Diesel Fuel 2016 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions Ll Disapproved <br /> L ee achment With Conditions) <br /> A p <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCO AN WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPA WITH <br /> 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\ __ t� Title n/ Date <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 parry must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Joseph Bagley for Bagley Enterprise$ITLE General Manager PHONE# 209-367-4800 <br /> ADDRESS 2370 Maggio Cir#4. Lodi CA 95240 <br /> SIGNATURE DATE 05/23/18 <br /> 2of6 <br />