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• • STATE I0 NUMBER' <br /> Y> <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TAN)(S 1 <br /> ..01..NEW..PERMIT - t 1 .OS..RENEWEO_PERMIT r + AZ.SANK..CLOSED t J_E9.DELEIE,.EROn�P}i�R ENO. <br /> ( 1 O2 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT 1 ) OE MINOR CHANGE (NO SURCHARGE), <br /> I OWNER <br /> NAME(CORPORATZON.INDIVIOUAL OR PVSLZC AGENCY) PUBLIC AGENCY ONLY <br /> Sari Joaquin County ( ) 01 FED ( ) 02 STATE (XI 03 LOCAL <br /> L T RIFT ADDRESS CITY STATE ZIP <br /> 222 E Weber Street Stockton to 95202 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> Micke . Grove Park <br /> -STREET ADDRESS NEAREST CROSS STREET <br /> 11793 N. Micke Grove Road Armstrong <br /> uTLrodi COUNTY I P <br /> -SanJoaquin _.95240 <br /> MAILING ADDRESS CITYfTATE LIP ' <br /> 4520 W. Eight Mile Rd. Stockton SA 9-5209 <br /> PHONE W/AREA CODE TYPE OF SUSINESS - <br /> 209-944-2444 ( 1 01 GASOLINE STATION (XI 02 OTHER Park <br /> ,NUMBER Of CONTAINERS RURAL AREAS ONLY t TOWNSHIP RANOE SEC7LON., y - <br /> 2 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> . DAYS: NANSI tAA\ST, NAME FIRST) AND RHONE W/ATEA COOL NIGHTS: NAMEILAST NAME FIRST) AND 'PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE)= YEAR MFG: C. YEAR INSTALLED lI UNKNOWN <br /> 0. CONTAINER CAPACITY: ��,', - GALLONS f 1 UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER TORE MOTOR VEHICLE FUEL OR WASTE OIL ? (XI 01 YES l ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> l 1 <br /> 01 UNLEADED ( 02 REGULAR f 1 03 PREMIUM ('*) 04 DIESEL ( 1 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> F <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE [ J INCHES 1 l CM V UNKNOWN <br /> B. 1 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 04 02 NON-VAULTED t 1 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (_>� 02 SINGLE WALLED I 1 03 LINED <br /> D. (�,} 01 CARBON STEEL f ) 02 STAINLESS STEEL 1 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE 1 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD l 1 08 BRONZE ( 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> I 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />