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E; <br />ENVIRONMENTAL HEALTHUE-PARTOtCEIVED <br />SAN JOAQUIN .COUNTY <br />600 East Main Street, Stockton, California 95202 DEC 0 2 2015 <br />Telephone; (209) 468-8420 Fair: .(209) 468-3433 <br />ENVIRONMENTAL <br />APPLICATION FOR UNDJERGROUNO STORA4E TANK RETROFIT OR'PjPjN(j4�(�L��j4�FWW7 <br />THIS PERMrr EXPIRES 180 6AYB'FROM 1HE;AP11ROVk DATE: INENCATE r+.ERMrr iyRE•HBLOw; <br />Q TANK RE1'R0FI"f 10 PIPING-REPAII31FtETItpFIT 8 tl10C.;.R00AIRIRETR0.Fl7 @'C iDLD•:67A4TJ15VR UP.GRApE <br />F EPA Site # PrOjecl Confect & Telephone Warty Welthman 408-213-6038 <br />AFacilit N <br />C Yame Tracy Blvd Shell & Mini Marl Phone•# 209-835-7606 <br />l Address y <br />L 3725 N. Tracy Blvd Tracy, Ca. <br />TGross•Streel <br />y Owner/Operaior Anabl 909-494-4728 <br />o Coptrabtdt Name- Service Station Systems j Phone f. 408-213-6038 <br />T Contrealorllddress 680 Qulnn.Ave CA Lic # 485184 blase B,Cej <br />A Insurer insurance Company of the West <br />p Work•Comp # WPL602190702 <br />7 ICC Technician's Name Mike Thomas Expiration Dat = f` <br />4. ICt;aristaller'e:Nsme Expiration Date ,mfr <br />Tank system work ares Tank.Slze Chemicals $!orad Ctrrerltl Alt <br />{is.4r�nldtnow�,,9ilgkdatso1a,17pCtrl,.Qkj Y <br />P ® Approved 8 Approved with conditions Disapproved <br />L (See -Attachment With Conditions) <br />A <br />N Plan Revlewers Name . <br />Date .. <br />s+i <br />Compliance Officer n h, 11/25/2014 <br />Indicate the responsible- party to. be billed for•addWonal EHD staff time expended beyond perm4 payment coverage per,ia6k, .If <br />the party designated below Is different- than the permit �hppitcant; e:0. prOpeniy 4Wner, the party muss aclinoii bdg4 this <br />responsibility for the billing by'signalure-and date -below. <br />NAME Marty Welthman TITLE. COmpllance OfflgorPHONE# (408) 213-6038 <br />ADARE68 .680 Quinn Ave. San Jose, 96112 <br />11/25/2014 <br />EH230038 <br />1 <br />0 <br />AanNcenre8l�rnwrs�t�P�l.�t ,, 'Lt' Itfe._ <br />E -Z <br />