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SAN JOAQUIN 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 REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Joe Bagley 209-367-4800 <br /> A <br /> C Facility Name San Joaquin County Sheriffs Ops #2 Phone # 209-468-4616 <br /> I Address 7000 N Michael Canlis Blvd , French Camp <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Anthony Hagerty Phone # 209-4684616 <br /> C Contractor Name Phone # <br /> o Bagley Enterprises, Inc 209-367-4800 <br /> N Contractor Address CA Lic # 774802 Class A B HAZ C-61 <br /> T 2370 Maggio Cir #4 Lodi CA 95240 <br /> R <br /> A Insurer StarNet Insurance Co Work Comp # BNUWC013674921 <br /> G ICC Technician 's Name Expiration Date <br /> T Andrew Bagley P � 11 /12/2022 <br /> R <br /> ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> ( i.e. 87 piping sump, 91 leak detector, UDC 1121 etc.) Installed <br /> TTA0504968 South Dsl Tank 20 , 000 ga 12/15/1989 <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 - q.8.4e0P... -- <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." <br /> General Manager 10/ 19/2021 <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 Bagley Enterprises , Joe Bagley TITLE General Manager PHONE # 209- 3674800 <br /> ADDRESS 2370 Maggio Cir #4 , Lodi CA 95240 <br /> SIGNATURE. j0;keP�L '( a9tey DATE 10/ 19/2021 <br /> 2of6 <br />