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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQM COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> ❑TANK RETROFIT )tRPIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# N-2406 Project Contact&Telephone# Joseph Bagley 209-367-4800 <br /> C Facility Name Morada Chevron Fast-N-Easy1160 Phone# 209-931-6154 <br /> I <br /> L Address 10878 N. Hwy 99 Frontage Rd Stockton CA 95212 <br /> 1 Cross Street MSL£ RZ, <br /> T <br /> Y Owner/operator Shawn Corporation (Ashraf Ali) Phone# 707-747-2955 <br /> o Contractor Name Joseph Bagley Phone# 209-367-4300 <br /> N Contractor Address 2370 Maggio Circle, 4Ste4, odiCALic#774802 ClasFB,C61(D21,D3 ,D40 <br /> T <br /> nInsurerMnnroeonropnqllranrp — Work Comp#1788626-07 <br /> cICC Technician's Certification Number Expiration Date <br /> T <br /> aICC Installer's Certification Number 5297791— Expiration Date 01/08/09 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved proved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name Date l-7 6 <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 AGENTS 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 /> APPI arrtsSlgraNre Title Contractor Date o/ /1 hoop <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Joseph Bagley TITLE President PHONE# 367-4800 <br /> ADDRESS 2370 Maggio 9mle, Ste 4 Lodi CA 95240 <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />