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�► i <br /> STATE ID NUMBER 00000014332006 <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(COPPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> L ( l 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CSTY STATE ZIP j <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> 900AS'COUNTW CLUB SERVICE ow, , <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1403 COUNW CLUB PERSHING <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95204 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 1403 COUN'i10( CLUB STOCKTON CA 95204 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-943-0748 (X) 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER OF CONTAINERS 7 <br /> URAL AREAS ONLY TOWNSHIP 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 /> 209-93 07 S /h rn 209-9 ,? <br /> "AZO ETE 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: 19778C. YEAR INSTALLED 1978 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 3000 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 ? ( ) 01 YES (X) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) <br /> 01 UNLEADED ( ) 02 REGULAR ( l 03 PREMIUM ( ) 04 DIESEL f ) 05 WASTE OIL ( 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. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM (X) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />