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` • _ v ` • STATE ID NUMBER 00000011285001 <br /> J ' <br /> APPLICATION FOR PERMIT TO OPA DERGROUND STORAGE TANK <br /> (Y�01 NEW PERMIT ( ) 05 RENEWED PERMIT TANK CL ( ) 09 DELETE FROM FILE (NO FEE) <br /> f 02 CONDITIONAL PERMIT f ) 06 AMENDED PERMIT f 1 CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CITY OF STOCKTON [ ) 01 FED f 1 02 STATE (Sd'.03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 425 N. EL DORADO STOCKTON CA 95202 <br /> II FACILITY <br /> FACILITY NAME C��„ O� siock ,,ov., �V\(J j/�,,.[ DEALER/FOREMAN/SUPERVISOR <br /> t.omakii"r_i COMPANY OFFICERS <br /> STPEET ADDRESS NEAREST CROSS STREET <br /> 110 W. SONORA COMMERCE <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95203 <br /> MAILING ADOPESS CITY STATE ZIP <br /> 110 W. SONORA STOCKTON CA 95203 <br /> PHONE W/APEA CODE TYPEOF BUSINESS <br /> 209-944-8552 ( ) 01 GASOLINE STATION (X) 02 OTHER FIRE STATION <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> N/A N/A N/A <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAIS: NAME`LA T NAME FIRST) ANt1DlG�PddHON W/ARBA CODE NIGHTS: NAME(LAST NAME FIR ;)_ANO PHONE W/AREA CODE <br /> 0� 0-r— .24-/v/- �,& R SAME �lLc- <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK C ) 04 OTHER: CONTAINER NUMBER.iW <br /> B. MANUFACTURER (IF APPROPRIATE): UNKNOWN YEAR MFG: C. YEAR INSTALLED 1960 f ) UNKNOWN <br /> D. CONTAINER CAPACITY: 1000 GALLONS ( ) 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 ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> L <br /> y V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES f ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f ) 02 NON-VAULTED (X1 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED f 02 SINGLE WALLED f ) 03 LINED <br /> D. ( ) 01 CARBON STEEL f ) 02 STAINLESS STEEL f ) 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD 1 1 08 BRONZE ( ] 09 COMPOSITE 1 ) 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/851 PAGE 1 <br /> PEN, , KN( <br /> �-- <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATINfL.,A`GENCV CITY CODE COUNTY CODE <br /> Qh <br /> CONTACT PERSON PHONE W/ARE.A CODE <br /> DATE OF LAST INSpPE/CTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID It <br /> - I <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) ` <br /> PAGE 2 <br /> 0 <br />