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STATE IO NUMBER <br />r <br />APPLICATION ,FOR PERMIT TO OPERATE UNDERGROUND �TORAG ? <br />DxIO1 NEW PERMIT ( ) 05 RENEWOMED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FR),ILE (NO FEE) <br />02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 0$ MINOR CHANGE (NO SURCH GE) <br />--/,r�.,e---------.._.._ T--1- 1 - <br />I OWNER <br />NAM'-(CCOOORATION.INDIVIOUAL OR PUBLIC AGENCY) PUBLIf6 vf/@ �p1/c <br />_CHEVRON USA INC . i [ 1 01 FED ( I 02 ( ) 03 LOCAL <br />STREET ACORESS CITY STATE ZIP <br />2 ANNABEL LANE, SUITE 200 SAN RAMON CA 94583 <br />II FACILITY <br />FACILITY NAME <br />DEALER/FOPEMEN/SUPERVISOR <br />CHEVRON SERVICE STATION <br />S.D. FELTON <br />STREET ACCESS <br />(C. (x1 01 <br />NEAREST CROSS STREET <br />2905 WEST BENJAMIN HOLT <br />DRIVE <br />PLYMOUTH <br />CITY <br />( ) 12 <br />COUNTY - <br />ZIP <br />STOCKTON <br />SAN JOAQUIN <br />95201 <br />MAILING ADDPESS <br />CITY - <br />STATE <br />ZIP <br />_29N5 WEST BENJAMIN HOLT <br />DRIVE <br />STOCKTON <br />CA <br />95201 <br />PHONE W,ACEA CODE <br />TYPE OF BUSINESS <br />( 209) 478-5555 <br />(X) 01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER CF CONTAINECS <br />PUPAL AREAS ONLY <br />TOWNSHIP _FN <br />GE <br />SECTION <br />THREE <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />LYS: NAME(LAST NAME FIPST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE <br />GRINCEWICZ, CHERYL {4175) 838-5331 SAME - - <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. (X) 01 TA)(K ( ) 02 OTHER: CONTAINER NUMBER N/A <br />B. MANUFACTURER ( IF APPROPRIATE): XERXES YEAR MFG: 198C. YEAR INSTALLED 1988 t ) UNKNOWN <br />0. CONTAINER CAPACITY: 10,000 GALLONS ( 1 UNKNOWN JE. DOES THE CONTAINER STORE: ( 1 01 WASTE (X 102 PRODUCT <br />F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />(X) 01 Ut.LEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL t -) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />HSC04-0 0185 <br />PAGE 1 <br />A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM [ ) UNKNOWN <br />B. ( 1 01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( ) 03 UNKNOWN <br />(C. (x1 01 <br />DOUBLE WALLED ( ) 02 SINGLE WALLED ( 1 03 LINED <br />D. 1 1 01 <br />CARBON STEEL ( ) 02 STAINLESS STEEL (XI 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br />( ) <br />06 ALUMINUM ( ) 07 STEEL CLAD (. 1 OE BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br />( ) 12 <br />UNKNOWN ( ) 13 OTHER: <br />HSC04-0 0185 <br />PAGE 1 <br />