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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (kY 01 NEW PERMIT f ) 05 RENEWED PERMIT l ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE lN0 FEE) <br /> TT-02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT 1 ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> San Joaquin County 01 FED f l 02 STATE ,t�101 03 LOCAL <br /> STREET ADDRESS CITY STATE 2IP <br /> 222 E. Weber Street .Stockton CA 9520 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMENISUPERVISOP <br /> San Joaquin General Hosoital Jeff Smith <br /> STREET ADD'ESS NEAREST CROSS TPEET <br /> 500 W. Hospital Rd. Manthe +i <br /> c>�Trench Camp DDSan Joaquin 195231 <br /> MAILING ADDRESS CITY STATE 2IP <br /> 520 W. Eiqht Mile Rd. I Stockton CA 95209 <br /> PHONE WIAPEA CODE TYPE OF BUSINESS <br /> 209_982_5070 f 1 01 GASOLINE STATION-fOLS02 OTHER County HOS ital <br /> NUMBER CF CONTAINERS PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 74 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> Smith, Jeff 20T 9A?-5070 Dispatcher 209-944-22 1 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. f 1 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER fIF APPROPRIATE): T'(`o W/ YEAR MFG: C. YEAR INSTALLED /99-5'( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: VOVV GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: 1 1 01 WASTE U(Y 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (L01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOXIES): <br /> 1 1 01 UNLEADED 1?()_02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL f 1 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE f 1 INCHES ( ) CM INUNCNOWN <br /> B. ( ) 01 VAULTED ILOCATED IN AN UNDERGROUND VAULT (>d 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED Q`02 SINGLE WALLED [ 1 03 LINED <br /> D. ,�-►. 1 CARBON STEEL 1 l 02 STAINLESS STEEL l ) 03 FIBERGLASS l ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> 1 ) 06 ALUMINUM 1 1 07 STEEL CLAD l ) 08 BRONZE f 1 09 COMPOSITE l ) 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />