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- T <br /> • • STATE ID NUMBER 00000010811001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> o( 1 1 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> l 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUALOR, RU9LIC GENCY) c PUBLIC AGENCY ONLY <br /> 0 <br /> 01 FED ! ) 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 1245 W. WEBER AVE STOCKTON CA 95203 <br /> II FACILITY <br /> FACILITY NAME DEA IER/FOREMA SUPERVSSOR <br /> iw� <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1245 W. WEBER AVE WASHINGTON <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95203 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P.O. BOX 1138 STOCKTON CA 95201 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-948-9400 ( ) 01 GASOLINE STATION (X) 02 OTHER BEER DISTRIBUTOR <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> $A81FA;-.R�.4. 209-948-9400 SAME le 1XI-77ir <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 12896 <br /> B. MANUFACTURER (IF APPROPRIATE): PERKINS WELDING YEAR MFG: 1974 C. YEAR INSTALLED 1974 f ) UNKNOWN <br /> D. CONTAINER CAPACITY: 10000 GALLONS ! ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED (X) 02 REGULAR ( ) 03 .PREMIUM ( ) 04 DIESEL f l 05 WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS Of PRIMARY CONTAINMENT: 1/4" ( ) GAUGE (X) INCHES ( ) CM f ) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (XI 02 SINGLE WALLED ( ) 03 LINED <br /> 0. (X) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( ] 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />