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STATE IO NUMBER 00000001912001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> X-01 NEW PERMIT ( l 05 RENEWED PERMIT ( 1 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 /> NA =_tCORPCRATION.IYDIVICUAL OR PUBLIC AGE CYl PUBLIC AGENCY ONLY <br /> x UL ( J <br /> 01 FED [ ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS S Z0GCITY SAC_(2-1001io STATE ZIP <br /> 9sz <br /> I I FACILITY O� G,6 r 3G5-��f�l <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> d G SWAP N F <br /> STREET ADOPESS NEAREST CROSS STREET <br /> 9571 S ROBERTS RD HOWARD ROAD <br /> CITY COUNTY ZIP <br /> ROBERTS ISLAND SAN JOAQUIN 93302 <br /> MAILING ADpF,E55 + STATE ZIP <br /> CITY <br /> G�5' STOCKTON CA 9520 <br /> PHONE W/AP.EA CODE TYPE OF BUSINESS <br /> of ( ) 01 GASOLINE STATION (X) 02 OTHER OIL & GAS PRODUCTION <br /> NUr^,9ER OF CCNTAINEP.S PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 1 TIS R6E 12 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AP,E.A CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER I <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1977 ( J UNKNOWN <br /> D. CONTAINER CAPACITY: 2000 GALLONS ( ) UNKNOWN JE. 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 SOX(ES): <br /> (X) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( l GAUGE f ) INCHES ( l CM (X) UNKNOWN <br /> B. ( J 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( 1 02 SINGLE WALLED ( J 93 LINED <br /> D. ( ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS [ ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> [ ) 06 ALUMINUM i ) 07 STEEL CLAD ( ) 08 BRONZE { 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />