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0 STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGR0UPD STORAGE TANK <br /> 06 01 NEW PERMIT ( ) 05 RENEWED PERMIT [ ) 07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE) <br /> �02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT t ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(C.OPPCRATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> San Joaquin Count [ 1 01 FED i ) 02 STATE 1� 03 LOCAL <br /> ..�� <br /> STREET ACr)RESS CITY STATE ZIP <br /> 222 E. Weber Street Stockton CA 95202 <br /> II FACILITY <br /> FACILITY NAME DEAL€R/FCPEMEN/SUPEPVISOP <br /> San Joaquin Co. - Courthouses Salp4�r+ (?,oyrn, B( <br /> STREET ACD=ESS NEAREST CROSS STPEET <br /> 222 E. Weber Street San Joa uin <br /> CITY <br /> COUNTY ZIP <br /> Stock San Joaquin <br /> MAILING ADOPESS CITY STATE ZIP <br /> / A$ E. Jce1 5 lav Stockton CA 9S�4S' <br /> PHONE W,A7EA CODE TYPE OF BUSINESS <br /> -�Yf- ;z rz�- 1 1 01 GASOLINE STATION (X) v2 OTHER Courthouse <br /> NUMBER CF CONTAINERS PUPAL AREAS ONLY ; TOWNSHIP RANGE SECTION <br /> III '4 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 /> Sa,l&mov% <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A01 TANK ( 1 02 OTHER: CONTAINER NUMBER - - <br /> B. MANUFACTURER (IF APPROPRIATE)= YEAR MFG: C. TEAR INSTALLED _UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS (Xf UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE PXI 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (>O 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM (>d 04 DIESEL ( ) 05 WASTE OIL [ 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. TNICY.NE55 OF PRIMARY CONTAINMENT: ( ) GAUGE: ( ) INCHES 1 ) CM I_WLjINKNOWN <br /> B. 1 101 VAULTED (LOCATED IH AN UNDEPGROUND VAULT) (lei 02 NON-VAULTED t ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED tid 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL f 1 02 STAINLESS STEEL I ) 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> /I ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BROE+ZE 1 ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> (.0 12 UNKNOWN ( ) 13 OTHER: <br /> iiSC04-070185 PAGE 1 <br />