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ENVIRON r_NTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN 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 /> U <br /> UTANK RETROFIT PIPING REPAIR/RETROFrr UUDC REPAIR/RETROFIT MOOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Bg le Enter rises 367-4800 <br /> C Facility Name City of Lodi Municipal Service Center Phone# 333-6706 <br /> 1Address 1331 S. Ham Lane <br /> L <br /> I Cross Street Kettleman Lane <br /> T <br /> Y Owner/Operator City of Lodi - Corporation Yard Phone# 333-6706 <br /> o Contractor Name Joseph Bagley Phone# 209-367-4800 <br /> T Contractor Address 2370 Maggio Cir, #4 Lodi 94240 CA Lic#774802 classB C61 D21 D3 ,D40; <br /> A Insurer Monroe & Monroe - General Liability work comp#WEN004519701 <br /> T ICC Technician's Certification Number 8014628 — UT Expiration Date Nov 18, 2010 <br /> R ICC Installer's Certification Number 8014628 - U1 Expiration Date Jul 31 2010 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T ;6-7 �zcrr►- <br /> N '3 2, 1 ril C-VtW 1' <br /> K <br /> P LlApproved Approved with conditions UDisapproved <br /> L } (See`Attachment with Conditions) <br /> 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 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 /> ApplicardsSigna�re f� TRIe Contractor Dace <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# 209-367-4800 <br /> ADDRESS 2370 Maggio Circle, Unit 4, Lodi, CA 95240 <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />