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• • <br /> STATE ID NUMBER 00000014332007 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) 1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 4102 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION INDIVIDU L OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS ( VQ F CITY STATE 2 <br /> II FACILITY F <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> COUNW CLUB SERVICE enn.�e—scrs <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1403 COUNTRY CLUB PERSHING <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95204 <br /> MAILING ADDRESS CITY STATE Zip <br /> 1403 COUNW CLUB STOCKTON CA 95204 <br /> PHONE W/.4P.EA CODE TYPE OF BUSINESS <br /> 209-943-0748 (X) 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBEP. OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> r <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/.4RE.4 CODE NIGHTS: NAME(LAST NAME FIRST) .AND PHONE W/AREA CODE <br /> .n�eer eutAsea 209-43'Y�`5iQ/ /-tJ7 . 514MYa <br /> C�f6 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1978 C. YEAR INSTALLED 1978 t l 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 ? ( ) 91 YES (X) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL 4L 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( ) CM (X) UNKNOWN <br /> B. ( 1 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 ( l 05 CONCRETE <br /> ( ) 06 ALUMINUM (X) 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( 1 lA NON-METALLIC <br /> ( } 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />