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STATE ID NUMBER 00000060135001 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />( ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( l 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br />OWNER <br />NAME(COPPOPATION,INDIVIDUAL OR PUBLIC AGENCY) / PUBLIC AGENCY ONLY <br />o(. ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />STREET ADDRESS ' _ — CITY f� ✓� STATE ZIP 445�^6 <br />II FACILITY <br />FACILITY NAME <br />K Id�on� Ndur <br />(mks <br />CONTAINMENT: 1/4 <br />DEALER/FOREM.AN/SUPERVISOR <br />1 CM ( ) UNKNOWN <br />B. <br />( ) 01 <br />VAULTED (LOCATED <br />IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />Leo,--\ 0 <br />C. <br />STREET ADDRESS <br />DOUBLE WALLED <br />(X) 02 SINGLE WALLED ( <br />NEAREST CROSS <br />STREET <br />D. <br />701 E. CHARTER WAY <br />CARBON STEEL <br />06 ALUMINUM <br />UNKNOWN ( ) <br />f ) 02 STAINLESS STEEL ( <br />( 1 07 STEEL CLAD ( l 08 <br />13 OTHER: <br />) 03 FIBERGLASS ( 1 04 <br />BRONZE ( ) 09 COMPOSITE <br />/"/#/V// <br />CITY <br />COUNTY <br />ZIP <br />STOCKTON <br />SAN JOAQUIN <br />95206 <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />701 E. CHARTER WAY <br />STOCKTON <br />-T-*- Cpl <br />95206 <br />PHONE W./AP CCp^ p3 �S <br />T(PE OF BUSINESS <br />X) 01 <br />STATION ( l 02 OTHER <br />GASOLINE <br />NUMBER OF CONTAII.NtERR"Sl <br />PUPAL <br />AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />2 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME( ) AND PHONE W/.�P�EpA CODE NIGHTS: NAME ) AND PHO'E W/ PEA CODE NEC)19 <br />b3W� SAME k. lac t4_C)o � �S�— /oI <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. (X) 01 TANK ( ) 04 OTHER: ICONTAINER NUMBER 1 <br />B. MANUFACTURER (IF APPROPRIATE): MODERN WELDING YEAR MFG: C. YEAR INSTALLED( l/12 -(X) UNKNOWN <br />D. CONTAINER CAPACITY: 12000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br />F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY <br />CONTAINMENT: 1/4 <br />(X) GAUGE ( ) INCHES ( <br />1 CM ( ) UNKNOWN <br />B. <br />( ) 01 <br />VAULTED (LOCATED <br />IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />l 03 UNKNOWN <br />C. <br />( ) 01 <br />DOUBLE WALLED <br />(X) 02 SINGLE WALLED ( <br />l 03 LINED <br />D. <br />(X) 01 <br />( ) <br />t 1 12 <br />CARBON STEEL <br />06 ALUMINUM <br />UNKNOWN ( ) <br />f ) 02 STAINLESS STEEL ( <br />( 1 07 STEEL CLAD ( l 08 <br />13 OTHER: <br />) 03 FIBERGLASS ( 1 04 <br />BRONZE ( ) 09 COMPOSITE <br />POLYVINYL CHLORIDE ( l 05 CONCRETE <br />( ) 10 NON-METALLIC <br />HSC04-070185 (10/18/85) PAGE 1 <br />