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ONVIRONME•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 />I (TANK RETROFIT )JPIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT []COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Joe 209-367-4800 <br />C <br />FacilityName Corporation Yard <br />Phone #209-468-3079 <br />I <br />L <br />Address 1810 Hazelton Ave. Stockton CA 95205 <br />T <br />Cross Street S. Della S t . <br />Y <br />Owner/Operator San Joaquin Count 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 />Contractor Address 2370 Maggio Cir, 414, Lodi 95240 <br />CA Lic # 774802 ClassB, C61 (D21, D34 <br />A <br />insurer Monroe & Monroe - General Liability <br />Work Comp # 1788626-07 <br />T <br />ICC Technician's Certification Number 5297791 - V1 <br />Expiration Date June 16 2011 <br />oICC <br />Installer's Certification Number5297791- <br />Ul and UC <br />Expiration Date 01 /0$/2009 <br />R <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />❑Approved proved with conditions ❑Disapproved <br />L <br />(S 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 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 />WoRKEWS 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 WORKERS COMPENSATION LAWS <br />OF CALIFORNIA." <br />Aa kmnts Skumhze Title Contractor Date <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 * 367-4800 <br />1 <br />,D40 <br />