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r4k)* To Ise pza499V60 <br /> ✓NK �� ' �� STATE ID NUMBER 00000009064001 <br /> APPLICATION FOR PERMIT II 11J UVtKAIF <br /> UNDERGROUNLT STORAGE TANK <br /> ( ) 01 NEW PERMIT ( 1 05 RENEWED PERMIT (K1 07 TANK CLOSED (� ) 09 DELETE FROM FILE (NO FE <br /> ( 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT f1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CCRPORATION,INDIVIDUAL OR PUBL C AGENCY)Rommmombp" PUBLIC AGENCY ONLY <br /> 1 p g {[ ( ) O1 FED f 1 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS CITY STATE q <br /> I'm VM cru reNo nie �o•vE II03 6 RpNTLAuD CT '4606T <br /> O CA ZIP <br /> c f i cv <br /> F M �)6 <br /> II FACILITY <br /> FACILITY NAME �'� Q� C DEALER/FOREMAN/SUPERVISOR <br /> �J PF, Arnl,rsA, nOL rO <br /> Y.: r L <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1601 FRENCH CAMP TURNPIKE SOUTH LINCOLN ST. <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95206 <br /> MAILING ADDRESS <br /> CITY STATE ZIP�M I60 <br /> ' Vy � STOCKTON CA 952 <br /> 01I <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> n *en ... <br /> m�� <br /> ?0 6 — ( 1 01 GASOLINE STATION (X) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> 1 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(L.AST NAME FIRST) AND PHONE W/AREA CODE <br /> 289 461f 905if A <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1972 ( 1 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 /> ( ) 01 UNLEADED (X) 02 REGULAR ( 1 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( 1 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/65) <br /> PAGE 1 <br /> S <br />