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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND (STORAGE TANK <br /> ( XQj KW PERMIT 1 1 05 RENEWED PERMIT 07 TANK CLOSED iL(/Y'U nl�11T1 09 DELETE FROM FILE (NO FEE) <br /> 1 or 02 CONDITIONAL PERMIT 1 l 06 AMENDED PERMIT f OB MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIOUAL ORPUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> Cha <br /> ( 1 01 FED 1 ) 02 STATE ( ) 03 LOCAL <br /> o <br /> STREET ADDRESS - CITY STATE ZIP <br /> 2010 W. Fremont Street Stockton CA 95203 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMEN/SUPERVISOR <br /> Chas. H. Bloom Co., Inc. Gary Bloom <br /> STREET ADD-ESS NEAREST CROSS STREET <br /> 2010 W. Fremont Street <br /> CITY COUNTY IIP <br /> Stockton San Joaquin 95203 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P. 0. Box 267 Stockton CA 95201 <br /> PHONE W/ACEA CODE TYPE OF BUSINESS <br /> 20 48-4121 [ 1 01 GASOLINE STATION 1X1 02 OTHER General Contractor <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 1 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: HAMEf LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> Bloom Gary 209' - 948-4121 Bloom ' Gary 209 - - 462-6041 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. f X1 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): MCCutchen, Inc. YEAR MFG: C. YEAR INSTALLED 1981 ( ) UIKH" <br /> D. CONTAINER CAPACITY: 5,000 GALLONS ( ) UROCNOWN E. DOES THE CONTAINER STORE: 1 ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHI L't FUEL OR HASTE OIL ? (X) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOXIESI: <br /> IXI 01 UNLEADED f 1 02 REGULAR ( '1 03 PREMIUM t 1 04 DIESEL ( 1 05 WASTE OIL l 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 10 (A GAUGE ( ) INCHES ( ) CM 1 ) UNKNOWN <br /> B. 1 ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED (X) 02 SINGLE WALLED [ 1 03 LINED =I�e�'Q <br /> D. (X) 01 CARBON STEEL t ) 02 STAINLESS STEEL t 103 FIBERGLASS ( 104 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> 1 ) 06 ALUMINUM l 1 07 STEEL CLAD ( ) 00 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> l ) 12 UIOCNOWN l 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />