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STATE iD NU(lBER 00000013749001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> O1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 47 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CCNDITIQNAL PERMIT t ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> i OWNER <br /> N4ME(CCF?OPATIONr2N0IVIDUAL OR PU3LIC AGENCY] PUBLIC AGENCY ONLY <br /> CIRCLE K CORPORkTION ( 1 01 FED ( ) 02 STATE t ) 03 LOCAL <br /> ----J <br /> ST?EET ADDRESS CITY" STATE ZIP <br /> 4500 SOUTH 40TH STREET PHOENIX AZ 85440 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPER50R <br /> CIRCLE K #1334 j r� <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 2650 MI DIABLO ST. <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95203 <br /> M4ILING ADOPESS CITY STATE ZIP <br /> 2650 MI DIABLO ST. STOCKTON -Q-C4# 95203 <br /> PHONE W/.APEA CODE TYPEOF BUSINESS <br /> ftF465-4763 (X) 01 GASOLINE STATION ( ) 02 OTHER <br /> N" M9EP OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> 3 <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%AR E.4 CODE <br /> 916-331-2540 - <br /> wi tc I? <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. tX) 01 TANK f l 04 OTHER' CONTAINER NUM5EP, <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG TC. YEAR INSTALLED (X) 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 ? tX) 01 YES t ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM f ) 04 DIESEL [ ) 05 WASTE OIL [ ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: E ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED t ) 03 LINED <br /> D. (XI 01 CARBON STEEL ( ) 02 STAINLESS STEEL t ) 03 FIBERGLASS t ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD t ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN f 1 13 OTHER: <br /> HSC04-070185 110/18/85) PAGE 1 <br />