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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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Joseph Bagley 209-3674800 <br /> C Facility Name San Joaquin County Fleet Svc - Sheriffs Ops # 1 Phone # 2094684645 <br /> 1 Address 7000 Michael Canlis Blvd , French Camp <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator County of San Joaquin Fleet Svc Phone # 2094684645 <br /> C Contractor Name Phone # 209 -367-4800 <br /> o Bagley Enterprises , Inc <br /> T Contractor Address 2370 Maggio Cir #4 Lodi CA 95240 CA Lic # 774802 Class A <br /> R <br /> A Insurer Midwest Employers Casualty Company Work Comp # BNUWC0136749 <br /> C ICC Technician ' s Name Expiration Date <br /> T Eric Molgaard P � 2/25/2019 <br /> R ICC Installer' s Name Eric Molgaard Expiration Date 2/25/2019 <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 /> 87 Octane TA0243701 25 , 000 1989 <br /> A Diesel (TA0243702 ) 61000 1989 <br /> N <br /> K <br /> P ❑ Approved Approved with conditions L ] Disapproved <br /> L ( See Attachment With Conditions ) <br /> A LL <br /> N Plan Reviewers Name as no Date `i nl 07 7 <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." ( � ' �/ � ^r✓5�t �ly .y,� , r <br /> Applicant's Signature \ /"" Title S �\ G FC ; %L � 4' 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 /> SIGNATURE 1 DATE <br /> 2of6 ORIGINAL <br />