Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY -� - I ' 9 � <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 r14 ' . 7, � . ':r, { I <br /> Telephone : ( 209 ) 468-3420 Fax : ( 209 ) 468-3433 <br /> NOV ' 12O1 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMI-NIUIRONl119e1AA HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW : 11 (� <br /> ❑ TANK RETROFIT X PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Joseph Bagley 209-3674800 <br /> A Facility Name San Joaquin Regional Transit District/Reg ' I Trans Center Phone # 209-467-6672 <br /> I Address 2849 E . Myrtle Street Stockton , CA 95205 <br /> L <br /> I Cross Street Filbert <br /> T <br /> Y Owner/Operator Darla Smith Phone # 209467-6672 <br /> C Contractor Name Bagley Enterprises , Inc . Phone # 209-3674800 <br /> O <br /> N Contractor Address 2370 Maggio Cir #4 , Lodi , CA 95240 CA Lic # 774802 Class A , B , HAZ C-6 <br /> T <br /> R <br /> A Insurer Midwest Employers Casualty Company work comp # BNUWC0136749 <br /> T <br /> T ICC Technician 's Name Expiration Date <br /> Q <br /> R ICC Installer' s Name Eric Molgaard 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 /> Diesel Transition Sump 40 , 000 gal #2 Diesel Fuel 2016 <br /> T <br /> A <br /> N <br /> K <br /> p ❑ Approved Approved with conditions ❑ Disapproved <br /> L ttachment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date <br /> j APPLICANT MUST PERFORM ALL WORK IN ACCOR CE 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." <br /> Ad,ijg <br /> Applicant's Signature Iz Title General Manager 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 for Bagley Enterprises TITLE General Manager PHONE # 209- 3674800 <br /> ADDRESS 2370 Maggio Cir #4 , Lodi , CA 95240 / <br /> SIGNATURES DATE <br /> EH230038 (revised 7-26-2016 ) 2 <br />