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FACILITY NAME <br />OEALER/FOPEMEN/SUPERVISOR <br />STATE ID NUMBER <br />APPLICATION FOR PERMIT TO <br />OPERATE UNDERGROUND STORAGE TANK <br />STREET ACD^ESS <br />(X) 01 NEW PERMIT <br />( ) 05 RENEWED PERMIT <br />t ) 07 TANK CLOSED <br />( ) 09 DELETE FROM FILE (NO FEE) <br />PLYMOUTH <br />- l 1 02 CONDITIONAL PERMIT <br />( ) 06 AMENDED PERMIT <br />( ) 0B MINOR CHANGE <br />(NO SURCHARGE) <br />I OWNER <br />f0. <br />JOAQUIN <br />99201 <br />MAILING AOOPESS <br />NAME(CCPPORATION.INCIVIDUAL OR <br />PUBLIC AGENCY) <br />STATE <br />22P <br />PUBLIC AGENCY ONLY <br />DRIVE <br />CHEVRON USA, INC. <br />CA <br />95201 <br />UNKNOWN ( l 13 OTHER: <br />( ) O1 FED ( ) 02 STATE t J 03 LOCAL <br />__jZIP <br />PHONE W•ACEA CODE <br />STREET A" RESS <br />TYPECF BUSINESS <br />209-) 478-5555 <br />CZTY <br />tX ) 01 GASOLINE STATION ( ) 02 OTHER <br />STATE <br />PUPA) AREAS ONLY <br />TOWNSHIP <br />2 ANNABEL LANE, SUITE <br />200 <br />THREE ---__- -- <br />SAN <br />RAMON <br />CA <br />94583 <br />II FACILITY <br />FACILITY NAME <br />OEALER/FOPEMEN/SUPERVISOR <br />CHEVRON SERVICE STATION <br />A. <br />S.D. FELTON <br />STREET ACD^ESS <br />B. <br />NEAREST CROSS STREET <br />2905 WEST BENJAMIN HOLT <br />DRIVE <br />PLYMOUTH <br />CITY <br />( X) <br />COUNTY .. <br />ZIP <br />- STOCKTON _.SAN <br />f0. <br />JOAQUIN <br />99201 <br />MAILING AOOPESS <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />CITY <br />STATE <br />22P <br />2.,905 WEST BENJAMIN HOLT <br />DRIVE <br />STOCKTON <br />CA <br />95201 <br />UNKNOWN ( l 13 OTHER: <br />PHONE W•ACEA CODE <br />TYPECF BUSINESS <br />209-) 478-5555 <br />tX ) 01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER CF CCNTPZVECS <br />PUPA) AREAS ONLY <br />TOWNSHIP <br />1PANGE <br />SECTION <br />THREE ---__- -- <br />_ <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE <br />GRINCEWICZ, CHERYL (-415•) 838-5331 <br />NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/APER CODE <br />SAME - - <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. (X) 01 TANK ( ) 02 OTHER: CONTA%HER NUMBER N/A <br />B. MANUFACTURER (IF APPROPRIATE): XERXES YEAR MFG: 19 8 C. YEAR INSTALLED 1988 ( 1 UNKNOWN <br />D. CONTAINER CAPACITY 10,000 GALLONS t ) UNKNOWN E. 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 />( t 01 UNLEADED (YJ 02 REGULAR ( ) 03 PREMIUM ( l 04 DIESEL ( ) 05 WASTE OIL t J 06 OTHER <br />V CONTAINER CONSTRUCTION <br />HSC04-0 1185 <br />PAGE 1 <br />I <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( <br />) CM ( 1 UNKNOWN <br />B. <br />( 1 <br />01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( X) <br />01 <br />DOUBLE WALLED ( l 02 SINGLE WALLED ( 1 03 LINED <br />f0. <br />( ) <br />01 <br />CARBON STEEL ( ) 02 STAINLESS STEEL (X) 03 FIBERGLASS ( ) 04 <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />II <br />( <br />) <br />06 ALUMINUM ( 1 07 STEEL CLAD ( 1 08 BRONZE ( l 09 COMPOSITE <br />( ) 10 NON-METALLIC <br />( 1 <br />12 <br />UNKNOWN ( l 13 OTHER: <br />HSC04-0 1185 <br />PAGE 1 <br />I <br />