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ENVIRONMENTAL 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 /> ❑TANK RETROFIT APING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Joe Bagley 367-4800 <br /> A <br /> c Facility Name SJC Corporation Phone#468-3079 <br /> I <br /> L Address 1810 Hazelton <br /> I Cross Street S. Della St. <br /> T <br /> Y owner/operator SJC Public Works, Fleet Service Dept Phone#468-3079 (Dave low) <br /> C Contractor Name Joseph Bagley Phone#367-48 0 <br /> O <br /> ."r Contractor Address 2370 Maggio Circle Ste 4 CA Lic#774802 Clas9,C61(D21,D34 D40 <br /> A InsurerMonroe & Monroe - General Liability work Comp# WEN004519701 <br /> C <br /> T ICC Technician's Certification Number 8014628-UT Expiration DateNov 11 2010 <br /> R ICC Installer's Certification Number 8014628—U1 Expiration DateJul 30 2010 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved proved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name C, c Date <br /> APPLICANT MUST PERFORM ALL WOK IN ACC DAN WITH SAN JOAQUIN COUNTY NANCES,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,1 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." N_ <br /> Applicants Signature Title General Manager Date ZS <br /> BILLING INFORMATION: <br /> Indicate the responsible kri/yto'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 Joss-ph Bagley TITLE General Manager PHONE# 367-4800 <br /> ADDRESS 2370 MagRio Circle Ste 4 Lodi. CA 95240 <br /> SIGNATURE <br /> EH230038(revised 12/31! <br /> 1 <br />