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STATE ID NUMBER 00000065876001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (X) 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> `rT02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVTDUAL OR PUBLIC AGENCY) FP(UB)L <br /> IC AGENCY ONLY <br /> SAN JOAQUIN COUNTY-h L_ 01 FED ( ) 02 STATE (?0"03 LOCAL <br /> STREET ADDRESS L FITY <br /> STATE ZIP <br /> Z� �, 11✓ebe�C TOCKTON CA 952QXZ <br /> II FACILITY <br /> FACILITY NAME DEALER/FOR MAN/SUPERVISOR <br /> t(asPss�t Saul To w i(\ &er"a_( i / Nm- �emaro6 <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 500 W. HOSPITAL ROAD Mar-Jhgy j <br /> CITYj� TY ZIP <br /> &+t3C-�i4*em �,� L� CLk Mjp SAN JOAQUIN 95231 <br /> MAILING ADDRESS CITY STATE ZIP <br /> POST OFFICE BOX 1810 STOCKTON CA 95201 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-944-3737 t ) 01 GASOLINE STATION (X) 02 OTHER COUNTY HOSPITAL <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY :JTOWNSHIP RANGE SECTION <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/AREA CODE <br /> DESMARAIS, NORMAN 209-944-3737 NIGHT WATCHMAN 209-944-2281 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK t ) 04 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 5000 GALLONS ( ) UNKNOWN JE. DOES THE CONTAINER STORE:ZO1 WASTE WT 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ; to 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 01 UNLEADED ( 1' 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL t ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES_,W'rCM (�Y UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 2 NON-VAULTED 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLEDy,02 SINGLE WALLED t ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( l 08 BRONZE ( ) 09 COMPOSITE i ) 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (08/29/86) PAGE 1 <br />