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STATE ID <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE�TANK <br /> 00000011283001 <br /> C7y)'O1 NEW PERMIT ( ) " RENEWED PERMIT f ) 07 TANK CLOSED <br /> 02 CONDITIONAL PERMIT f ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) ) 09 DELETE FROM FILE (NO FEE) <br /> I OWNER <br /> NAME(COPPORATION,INDIVIDUAL OR PUBLIC AGENCY) <br /> CITY OF STOCKTON PUBLIC AGENCY ONLY <br /> ET ADDRESS <br /> ( ) 01 FED ( 7 02 STATE <br /> 425 (�Y 03 LOCAL <br /> 425 N. EL DORADO DITY <br /> STOCKTON STATE Zip <br /> CA 95202 <br /> II FACILITY 4 - <br /> FACILITY NAME �/ G��h DEALER/FOREMAN/SUPERVISOR <br /> OMPANY OFFICERS <br /> STREET ADDRESS <br /> 5525 PACIFIC AVE NEAREST CROSS STREET <br /> ROBINH00D <br /> CITY <br /> STOCKTON COUNTY <br /> SAN JOAQUIN ZIP <br /> MAILING ADDRESS 95207 <br /> 5,525 PACIFIC AVE CITY <br /> STOCKTON STATE ZIP <br /> PHONE W/AREA CODE C'A 952D7 <br /> 209-951-6113 TYPE OF BUSINESS <br /> f ) 01 GASOLINE STATION (X) 02 OTHER FIRE STATION <br /> NUMBER OF CONTAINERS <br /> 2 RURAL AREAS ONLY TOWNSHIP <br /> RANGE SECTION <br /> N/A N/A <br /> N/A <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(lA T NAME FIRST) AN 0 PHONE W'fAREA CODE <br /> ' lo)5 P� 8/ NICO M7S: ,LlA ME(IAST NAME FIRST) AND PHONE W/AREq CODE <br /> .�9- t�- ,47 J//) lierX09 (05��1 <br /> )s <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK f 104 OTHER: I <br /> CONTAINER NUMBER JW 1 <br /> B. MANUFACTURER (IF APPROPRIATE): UNKNOWN TALLER <br /> YEAR MFG: C. YEAR INSTALLED 1967 ( ) UNKNOWN <br /> D. CONTAINfR CAPACITY: 550 GALLONS f ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> THE <br /> MOTOR <br /> F. DOES01 UNLEADED 02 <br /> STORE <br /> REGULARVE(IC L03FUEL OR PREMIUMWASX) 04 TE LDIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> (X) 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(E3): <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( ) INCHES ( 1 CM (X) UNKNOWN <br /> B. ( ] 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 1 02 NON-VAULTED (X) 03 UNKNOWN <br /> C• ( 1 01 DOUBLE WALLED 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL f ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 7 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE <br /> (X) 12 UNKNOWN ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> f ) f OTHER: <br /> SC04-070185 (10/18/85) <br /> PAGE 1 <br />