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STATE ID NUMBER <br /> APPLICATION `FOR91RMIT TO OPERATE UNDERGROL10 STORAGE TANK <br /> 1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> L-4—(0c <br /> 2 CONDITIONAL PERMIT l ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CCPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> S Joa U Unt ( ) 01 FED ( ) 02 STATE 1�!L03 LOCAL <br /> SLGETEADeUSe CITY ST�jE Z195202 t <br /> [[[ Stockton f�{{ <br /> II FACILITY <br /> FACILITY NAME DEALER/FCREMEN/SUPERVISOP. <br /> San Joaquin General Hospjldl - Govern. Bldg. Jim Salamon Director <br /> STREET ACD=ESS NEAREST CROSS STREET <br /> 500 W. Hospital Rd. Mar*Ke <br /> CITY COUNTY ZIP <br /> &roelt," Fre kc-k Cal.► -t P San Joa u i n <br /> MAILING ADOPESS CITY STATE ZIP <br /> 1722 E. Scotts Ave. Stockton _ CA 95202 <br /> PHONE WIAPEA CODE TYPE OF BUSINESS <br /> .2001 9VY 2/7-7 ( ) 01 GASOLINE STATION QL 02 OTHER Hospi tal <br /> NUMBER CFf ONTAINERS PUPAL AREAS ONLY TOWNSHIP PANGE 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 /> ala r)non T r)c� =9`1y 2l;�-7— la's a.�ck e r 3r7 q y 4 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A._Q!�f 01 TANK t 1 02 OTHER: CONTAINER NUMBER 3 <br /> B. MANUFACTURER (IF APPROPRIATE): 15 6r nI YEAR MFG: TEAR INSTALLED UNKNOWN <br /> D. CONTAINER CAPACITY: L5_ GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE X02 PRODUCT <br /> f <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? j'_Ad_01 YES I ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): - <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ` T 04 DIESEL ( l 05 WASTE OIL t ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: t ) GAUGE ( ) INCHES ( ) CM J)d UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (k) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (x'02 SINGLE WALLED ( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL (jd 03 FIBERGLASS t ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE (. ) 10 NON-METALLIC <br /> t ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />