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0 STAT&MIME R 00000021346001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( l 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARG ) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> BLOOM'S AUTO PARTS, INC. ( ) 01 FED ( ) 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS CITY STATE 2IP <br /> 2546 TURNPIKE ROAD STOCKTON CA 95206 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> BLOOM'S AUTO PARTS, INC. DAVID BLOOM <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 2546 TURNPIKE ROAD 9TH STREET <br /> CITY COUNTY IIP <br /> STOCKTON SAN JOAQUIN 95206 <br /> MAILING ADDRESS CITY STATE 2IP <br /> 2546 TURNPIKE ROAD STOCKTON CA 95206 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-466-5423 ( ) 01 GASOLINE STATION (X) 02 OTHER AUTOMOBILE RECYCLER <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/ARCA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> DAVID BLOOM 209-466-5423 DAVID BLOOM 209-467-1020 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER ONE <br /> B. MANUFACTURER (IF APPROPRIATE): LEE WALTHALL YEAR MFG 1984 C. YEAR INSTALLED 1984 ( l UNKNOWN <br /> D. CONTAINER CAPACITY: 1200 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: (X) 01 WASTE f ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) Ol YES (X) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 3 1/2 ( ) GAUGE (X) INCHES ( ) CM ( l UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> 0. f ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE IX) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 . <br />