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STATE ID NUMBER 00000056885001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( D 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( D 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> GARY BURGIN ( D O1 FED ( ) 02 STATE ( l 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 2810 RICHLAND CT. STOCKTON CA 95207 <br /> Il FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> WATERLOO FOOD A FUEL GARY BURGIN <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 3032 E. WATERLOO RD. SUTRO <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95207 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 3032 E. WATERLOO RD. STOCKTON CA 95207 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-466-5816 (X) 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER OF CONTAINERSRURAL 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) A14D PH NE W/AREA CQD� <br /> GARY BURGIN 209-478-8660 SAME - '�$ "}}vv(( <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( D 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: FCYEAR INSTALLED (X) NKNOWN <br /> 0. CONTAINER CAPACITY: 5000 GALLONS ( ) UNKNOWN JE. DOES THE CONTAINER STORE: ( D 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> t ) 01 UNLEADED ( ) 02 REGULAR (X) 03 PREMIUM ( ) 04 DIESEL t D 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( l GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( D 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> 0. ( ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( D 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> SC04-070185 (10/18/85) PAGE 1 <br /> C � <br />