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STATE IO NUMBER 00000059148003 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL ORCLIC OENCY) PUBLIC AGENCY ONLY <br /> f ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CA� 9. L`O C TY / CRATE ZIP <br /> alo <br /> II FACILITY U D /Tri <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> KING ISLAND RESBRfi-4-MARINA t:ARRT KLUPrEMS+EW <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 11530 WEST EIGHT MILE RD. INTERSTATE 5 <br /> CITY COUNTY ZIj <br /> STOCKTON SAN JOA(RUIN 99 <br /> MAILING ADDRESS CITY STATEIP11530 WEST EIGHT MILE RD. STOCKTON CA 5209 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-478-etty (X) 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RA NOE SECTION <br /> 3 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAM'- FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/ARCA CODE <br /> 209- _7,(gg REYN6+95T'R6M 209- - <br /> J COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 3 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 4000 GALLONS ( l UNKNOWN E. DOES THE CONTAINER STORE: ( ) 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 /> ( ) <br /> 01 UNLEADED (X) 02 REGULAR ( 1 03 PREMIUM ( ) 04 DIESEL f ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. l ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED f ) 03 LINED <br /> D. ( 1 01 CARBON STEEL f 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l ) 05 CONCRETE <br /> f ) 06 ALUMINUM l ) 07 STEEL CLAD [ ) 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> ti/ <br />