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STATE ID NUMBER, 00000057860001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 4-01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED — <br /> ' ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE)) 09 DELETE FROM FILE (NO FEE) <br /> OWNER <br /> �N-'ME(CC:;POPATION.INDIVIDUAL OP PUBLIC AGENCY) - <br /> PACIFIC BELL TLIC AGENCY ONLY <br /> 01 FED ( ) 02 STATE ( 1 03 LCCAL <br /> k;7PEST ADDRESS <br /> '3 �o� CITY STATE ZIP <br /> II FACILITY <br /> FACILITY ELL <br /> PACIFIC SELL DEALER/FOREMAN/SUPERVISOR <br /> (UE-I48} [ fL E.J.KOEHLER <br /> �STTEET .ADDRESS <br /> REDWOOD & 6TH STS. (FRENCH CAMP) NEAREST CROSS STREET <br /> CITY <br /> STOCKTON COUNTY ZIP <br /> SAN JOAQUIN 95205 <br /> 11ING ADDRESS CITY <br /> STATE ZIP <br /> �- y ` i� �r S+4N-'FR#f�fS£�� CA T <br /> PHONE W/r.rEA CODE TYPE OF BUSINESS <br /> ( 1 01 GASOLINE STATION (X) 02 OTHER SIC 4800 <br /> NUMBER OF CONTAINERS =RURAL ARE=0NLYTOWNSHIP <br /> 1 RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS, NAME(LAST N.tNE FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(L.AST NAME FIRST) AND PHONE W/AREA CODE <br /> EMERGENCY CONTROL CENTER 415-�r4c�-4bg7 � SAME �7 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORA FOR EACH CONTAINER <br /> IV DESCRIPTTON <br /> A. (X) 01 TANK f ) 04 OTHER: 'CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG- =C. YEARINSTALLED 2982 ( ) UNKNOWND. CONTAINER CAPACITY: ';'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 /> ( 1 01 UNLEADED f ) 02 REGULAR ( 1 03 PREMIUM (X) 04 DIESEL { ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> ETHICKINESS OF PRIMARY CONTAINMENT f ) GAUGE f ) INCHES ( ) CM (X) UNKNOWN <br /> LTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( 1 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED 1 1 <br /> 02 SINGLE WALLED C 1 03 LINED <br /> D. f ) 01 CARBON STEEL ( } 02 STAINLESS STEEL (X) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( } 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE f ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> ISC04-070185 (1.0/18/85) <br /> PAGE 1 <br />