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ENVIRONMENTAL HEALTH DEPART ' <br /> SAN JOAQUIN COUNTY E D <br /> 600 East Main Street, Stockton, California 95202 N U V 2 12017 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANBNVIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <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 8 Telephone# <br /> C Facility Name LODI MUNI SERVICE CENTER Phone# 2093 <br /> I Address 1331 S. Ham Lane, Lodi, CA 95242 <br /> L <br /> I Cross Street Kettleman Ln <br /> T <br /> Y Owner/Operator City of Lodi Phone# 209-333-6800 <br /> C Contractor Name Baqley Enteeprisew, Inc/. Phone# 209-367-4800 <br /> 0 <br /> T Contractor Address 2370 Ma.c�-%�CLv-, Stel4, Lode, 95240 CA Lic# 774802 ClassB. 2 ,D40 <br /> A Insurer Berkely Net Work Comp# BNUWC0136749 <br /> T ICC Technician's Name Eric Molgaard Expiration Date 2/25/2019 <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> Tank #2 2, 000 gal Unleaded 87 on file <br /> T <br /> A <br /> N <br /> K <br /> P L_ Approved __ Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A 1 /1? <br /> Z1- I / <br /> N Plan Reviewers Name ✓ Date II Z <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 <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE PERFORMANC 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 �"� TiUe r `�` '` C �°Date �F �'5� 1 <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 acknowledge <br /> this responsibility for the billing by signature and date below. <br /> NAMEJT�h8 , Ba Ley Entevpr4e4, I7 VE Gevtera,M PHONE# 209-367-4800 <br /> ADDRESS 2370 Ma.Vio-CLr, Stei4, Lod,, CA 95240 <br /> SIGNATURE DATE 7 <br /> EH230038(revised 07/22/1 ) <br /> 2 <br />