Laserfiche WebLink
M � <br /> STATE ID NUMBER 00000014332004 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> S-01 NEW PERMIT t l 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> E l 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) FP(UB) <br /> IC AGENCY ONLY <br /> SI#ftRBf)$r iMt:- 01 FED ( l 02 STATE ( ) 03 LOCAL <br /> JSTREET ADDRESS CITY STATE ZIP C " -7 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> COUNT' CLUB SERVICE <br /> ,44 <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1403 COUN-W CLUB PERSHING <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95204 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 1403 COUNTK CLUB STOCKTON CA 95204 <br /> PHONE W/AP.EA CODE _ TYPE OF BUSINESS <br /> 209-943-.0748 (X) 01 GASOLINE STATION f 1 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY 1T�NSHIP RANGE SECTION <br /> w <br /> ITI 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 /> @ 209-95t-57H ` L4 7-(,Tj RBB ERT <br /> fE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( l 04 OTHER: CONTAINER NUMBER// <br /> B. MANUFACTURER (IF APPROPRIATE)= YEAR MFG: 1978 C. YEAR INSTALLED 1978 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY= 3000 GALLONS [ ) UNKNOWN JE. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES (X) 02 NO `��IF' YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL L-+J_06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( l 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> 0. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 105 CONCRETE <br /> ( ) 06 ALUMINUM (X9 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( l 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />