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\.w *'moo STATE ID NUMBER 00000001407005 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (& 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,ZNDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> SKIPS SERVICE STATION ( ) 01 FEO ( ) 02 STATE [ l 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 300 3 CALIFORNIA ST STOCKTON CA 95206 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> SKIPS SERVICE STATION SKIP SMUTS <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 300 S CALIFORNIA ST. LAFAYETTE <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95206 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 300 S CALIFORNIA ST. STOCKTON CA 95206 <br /> PHONE W/AREA CODE TYPEOF BUSINESS <br /> 209-466-0005 (X) 01 GASOLINE STATION f ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 5 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> SMUTS, SKIP 209-466-0005 SMUTS, SKIP 209-951-1190 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 5 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1982 ( l UNKNOWN <br /> D. CONTAINER CAPACITY: 10000 GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: f ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL ( 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( ] INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> D. K.) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> I_ ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE 1 ) 09 COMPOSITE ( l 10 NON-METALLIC <br /> !i(d 12 UNKNOWN f 1 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> Y <br />