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... ..� <br /> � STATE IO NUMBER 00000004195001 <br /> 1 APPLICATIOV FOR PERKfT TO OPERATE UNDERGROUND STORAGE TANK <br /> tJG 01 NEW PERMIT 05 R�FWEWED PERMIT ( ) 07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT ,: '614HENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> C d1A/LW/9 PRD eon? , t ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 5045 WILSHIRE BLVD. LOS ANGELES CA 90036 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SVPERVISOR <br /> CARnATieH-9Z"4NG A-,(qyA'yct Avo coiRp. J811H GRIFFIN N4 R of /'FE-'L <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 4004 SO. ELDORADO <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95206 <br /> MAILING ADDRESS CITY STATE ZIP <br /> PO BOX 1079 STOCKTON CA 95201 <br /> PHONE W/AREA COO�!jp / TYPE OF BUSINESS <br /> A*-OAZ�914 /O Z-Lf 7�Z ( ) 01 GASOLINE STATION (X) 02 OTHER FEED MILL <br /> .�� <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 6 <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 /> lIgQQ✓'j V 9y1-4&F9 `�(y Z(/ 1 Z , .271 ICK DEWEESE 209-952-7640 _ybys <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 0001 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (XI UNKNOWN <br /> 0. CONTAINER CAPACITY: 5000 GALLONS f ) 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 /> (X) 01 UNLEADED f 1 02 REGULAR t ) 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( 1 CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 1 ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED V402 SINGLE WALLED l 1 03 LINED <br /> 0. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS t ) 04 POLYVINYL CHLORIDE ( l 05 CONCRETE <br /> ( ) 06 ALUMINUM f 1 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />