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F -Ta <br />0 <br />ENVIRONM&TAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, CaNfornia 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br />DTANK RETROFIT ;KpipiNG REPAiRnmrRoFiT EIUDC REPAIPjRETRoFtT ElcoLD sTARTiEvR UPGRADE <br />F <br />EPA Sile # <br />Projed Contact & Telephone # J-o,�- <br />C <br />Facility Nam SV -C <br />Phone # <br />L <br />Address /,)'1/0 <br />T <br />Cross Street <br />Y <br />[0wr'er/0I)a1`3t0r San Joaquin County (Dan McCann -Fleet Manager) <br />Phone #468-3106 <br />C <br />0 <br />Contractor Name Joseph Bagley <br />Phone #367-4800 <br />N <br />T <br />ContractmAddress 2370 Maggio Cir, 114, Lodi. 95240 <br />CA Lic # 774802 ClassB, C61 (D21, D34 <br />R <br />A <br />insurer Monroe & Monroe - General Liability <br />work comp # 1788626-07 <br />C <br />T <br />ICC Technician's Certification Number 5297791 - V1 <br />Expiration Date June 16, 2011 <br />0 <br />R <br />ICC Installer's Certification Number5297791- <br />U1 and UC <br />Expiration Date01/08/2009 <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Cuffently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />ElApproved PfApproved with conditions rlDisapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name 4_Z_11001 <br />Date _L( -t <br />6z <br />If V <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 />N A <br />WORKERS COMPENSATION -AVq OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY <br />THAT IN THE PERFORMANCE ThE WORK FOR WHICH THIS PERMIT IS ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAM <br />OF CAUFORNW <br />AWIcants SkIrohme Toe Contractor <br />&/ I/ f- 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 dffWent than the permit applicaK e.g. properV owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME- Joseph Bagley —TITLE President -------PHONE q 367-4800 <br />EH23OW8 (revised 1 <br />Circle, A, Lodi, CA 95240 <br />go <br />