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0 <br />0 RECEIVEC, <br />JAN 05 2016 <br />KIVI RON MENT_-! o <br />F41=4?Tr1 n��eT�r;irAr7 <br />ENVIRONMENTAL HE LTH MEPART��E�V�� <br />-SAN JOAQU N .COUNTY <br />600 East Main Street, Stockton, Cali Onds, 0.5202 DEC 0 2 2015 <br />Telephone: tZ09) 468-3420 Fat {209) 46W4$3 <br />APPLICATION FOR UNDERGROUND STORA4L TANK_ RETROFIT 09 -PIPIN ENVIRONMENTAL <br />�74O NI' <br />THIS PERMrr QXFItiF.a id0 DAyS'MOM IKAPP)MAL DATE: INDICAU P91U PE'B9LOWt <br />® TANK ItMOFrr 10 PIPING IttPAIR/AgThOPIT IIP.ORAPE <br />F EPA site 7Prdiect•Confect & Telephone #-Marty Welthmen 448-213-6038 <br />A Faculty Name Tracy Blvd Shell & Mini Mart Phone # 249-8311-7648 <br />I Address <br />1. 3726 N. Tracy Blvd Tracy, Co. <br />I Cross•Strest <br />T <br />Y Owner/0perator AnablPhoOe 909-M-4728 , <br />.0 Copirahtol' Name Service Station Systeme I?Ic6ne4 408-213-6038 <br />T 0ontraotorAddress 680 Quinn Ave GA 1.110 0' 485164 Mass 8,C61/D40 fb <br />A Insurer Insurance Companx of the West Work -Comp # WPL502190702 <br />7 II:C ler niclen's Narind Ike Thomas ExpjmtIon <br />a. 100.1ifettliiieri Naft Eviration Date <br />%rIk system want area Ta c.STrp Chemicals• $toren Purrs <br />rfrptaho«�nn.lrr <br />#A 1"k data". um w.*w <br />T <br />A <br />' N <br />K <br />P <br />APp�ad ,� Approved with condiUone 15 Oi;*Pproved <br />A (See.Attsohment With Conditions) <br />N Plan Revlewere Name ' � .� � �� 0.d-II't _ Dole—.j— _ b <br />APPLICANT MUST PERFORM A64 WORKM ACGOnDANCE WITH SAN JDA01AN CbL#fr( 0*bWAanPi -ATaTr- rAWAa 1u n, bf1fk: him; .*, . A. L; . <br />Of THE WORK -FOR WHralr THIS F'RMrr IS 10OUED, I <br />CornplIonoe Officer (f% <br />indicate the responsible- party to. be billed for•addklonal END staff time &penda4 beyond p" 0ayrnanl coverepe perlrs k, IP <br />the party designated below Is different- than -the permtl *ppIl"Pt; r£:0. property gwner, the party mini PoRtm- odpp Phis <br />responsibility for tho blHiMby'signalure•and date -below. <br />NAMR, Marl)+ Welchman Tm p Cofnplianca pff ger pfd E11 (408) 213-6038 <br />AOlN3$s8 . t380 gglnn AvQ. San Jpse, 96112 <br />eLdo.n,fwm .nom 1 .tt i• /A !`rl / V • ' /1•,/ !•'�....-iJ� J ,......._r , <br />EN230038 <br />1 <br />0 <br />