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• STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) 1 NEW PERMIT X ) 05 RENEWED PERMIT ( l07 TANK CLOSED-I /n/�6 ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT f ) 06 AMENDED PERMIT 04 MINOR CHANGE fN0 SURCHARGE) <br /> I OWNER <br /> NAMEf CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> SHEPHERD & GREEN ( ) 01 FED 1 ) 02 STATE ( ) 03 LOCAL <br /> STREET AOnRESS CITY STATE ZIP <br /> 826 N. El Dorado Street Stockton Calif 95202 <br /> II FACILITY <br /> FACILITY NAME DEER/FOREMENISUPERVISOR <br /> --SHEPHERD & �RyEN e <br /> STREET ADDPESS NEAREST CROSS STREET <br /> 810 S. B" y <br /> CITY Stockton COUNT Jan Joaquin ZIP 95206 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 826 N. El Dorado St . Stockton CA 95202 <br /> PHONE_ W/APEA CODE TYPE OF BUSINESS <br /> .209- 466-5177 t ) 01 GASOLINE STATION K ) 02 OTHER General Contractor <br /> NUMBER OF CONTAINERS PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> One <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> OATS: NAME(LAST NAME FIRST) AND PRONE W/AREA CODE NI GXTS: NAMEfLAST NAME FIRST) AND PHONE W/AREA CODE <br /> Shepherd John 209- 466-5177 Shepherd John 20°- 477-6156 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION _ <br /> A. X 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ) UNKNOWN <br /> 0. CONTAINER CAPACITY: 2 00 0 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> F. ODES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? Q YES ( l 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ]C LEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( 1 04 DIESEL L ( ) 05 WASTE OIL [ l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: (7 UGE ( ) INCHES ( ) CM ( 1 UNKNOWN <br /> B. t ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (i!102NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X ) 02 SINGLE WALLED ( ) 03 LINED <br /> D. f $✓0' 'CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 7 04 POLYVINYL CHLORIDE ( 7 05 CONCRETE <br /> ( 1 06 ALUMINUM f ) 07 STEEL CLAD f 1 08 BRONZE f 109 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />