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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 # Joseph Bagley 209-367-4800 <br /> C Facility Name San Joaquin County Fleet Svc - Corp Yard Phone # 2094684645 <br /> L <br /> Address 1810 E Hazelton Ave , Stoctkon , CA <br /> I Cross Street <br /> T <br /> Y Owner/Operator County of San Joaquin Fleet Svc Phone # 209-4684645 <br /> o Contractor Name Bagley Enterprises , Inc Phone # 209-3674800 <br /> T Contractor Address 2370 Ma io Cir #4 Lodi CA 95240 CA Lic # 774802 Class A <br /> R Insurer Midwest Employers Casualty Company Work Comp # BNUWC0136749 <br /> A <br /> C ICC Technician ' s Name Expiration Date <br /> T Nicholas Graham -Lewin P � 5/21 /2020 <br /> Q <br /> R ICC 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 1 /2 , etc.) Installed <br /> T <br /> A Diesel (TA508122 ) 15 , 000 1998 <br /> N <br /> K <br /> P El Approved A Approved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions) <br /> A <br /> N ��'�� <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 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." Lp�%11/1 �2 <br /> Applicant's Signature rl� G= �2f �� Title 5 ✓ s � � 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 party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Joseph Bagley , Bagley Enterprises TITLE General Manager PHONE # 209-3674800 <br /> ADDRESS 2370 Maggio Cir #4 , Lodi , CA 95240 <br /> 7 <br /> SIGNATURE � DATE 4:5 / <br /> 2 of 6 <br />