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STATE ID NUMBER 000000143i <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> —L) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( .) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COP.POP.ATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> © l� ( ) 01 FED ( l 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> s,�Tw mgt <br /> II FACILITY <br /> FACILITY NAME f b � k Shop - " <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1403 COUNTY CLUB PERSHING <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95204 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 1403 COUNTY CLUB STOCKTON CA 95204 <br /> I <br /> PHONE W/AREA CODE TYPEOF BUSINESS <br /> 209--943=GT48 �7 Z (X) 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY :TOWNsmlll <br /> RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: N.AME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> R 209-AL31-32bk-- fLt5Zog"?_ 209 _ ?31-1Z-76- <br /> E THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 3 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1976 C. YEAR INSTALLED 1976 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 10000 GALLONS ( l UNKNOWN JE. 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 ( l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES t ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL [ ) 03 FIBERGLASS ( l 04 POLYVINYL CHLORIDE ( l 05 CONCRETE <br /> ( ) 06 ALUMINUM (X) 07 STEEL CLAD { l 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> NSC04-079185 (10/18/85) PAGE 1 <br />