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STATE ID NUMBER <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />(X) 01 NEW PERMIT ( ) 05 RENEWED PERMIT t ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />( ) <br />02 CONDITIONAL PERMIT l ) 06 AMENDED PERMIT ( ) 0$ MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAME(CCPOORA'ION.INCIVIDUAL OR PUBLIC AGENCY)T�i <br />LIC AGENCY ONLY <br />_CI VRON USA, INC . <br />01 FED ( 1 02 STATE ( D 03 LOCAL <br />STREET AC^KESS - CITY STATE 2IP <br />AN <br />2 ANNABEL LE, SUITE 200 SAN RAMON CA 94583 <br />II FACILITY <br />FACILITY NAME <br />DEALER/FOREMEN/SUPERVISOP. <br />A. <br />SERVICE STATION <br />) CM ( ) UNKNOWN <br />S.D. FELTON <br />t ) 01 <br />STREET ACCESS <br />) 03 UNKNOWN <br />NEAREST CROSS STREET <br />(X) 01 <br />2905 WEST BENJAMIN HOLT <br />DRIVE <br />PLYMOUTH <br />( ) 01 <br />CITY <br />POLYVINYL CHLORIDE l ) 05 CONCRETE <br />COUNTY <br />v <br />( ) <br />ZIP <br />STOCKTON <br />SAN JOAQUIN <br />UNKNOWN ( l 13 OTHER: <br />95201 <br />MAILING AODPESS <br />CITY <br />STATE <br />ZIP <br />1 <br />05 <br />__29WEST_BENJAMIN HOLT <br />DRIVE <br />STOCKTON <br />CA <br />95201 <br />PHONE W -ACEs CODE <br />TYPE OF BUSINESS <br />{ 209 ) 478-5555 <br />( X) 01 GASOLINE STATION ( ) 02 OTHER <br />NUMBEP CF CONTAINEPS <br />PUPAL AREAS ONLY <br />TOWNSHIP <br />PANGE <br />SECTION <br />THREE <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIPST) AND PHONE W/APEA CODE <br />GRINCEWICZ, CHERYL (415) 838-5331 <br />NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />SAME - <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. (X) 01 TA)tK ( l 02 OTHER: <br />B. MANUFACTURER ( IF APPROPRIATE): XERXES <br />CONTAINER NUMBER N/A <br />YEAR MFG: 1981 C. YEAR INSTALLED 1988 ( ) UNKNOWN <br />0. CONTAINER CAPACITY: 10,000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE (X) 02 PRODUCT <br />F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />( ) <br />01 U.NLEADED ( ) 02 REGULAR (X) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />HSC04-07^185 <br />n <br />C7 <br />PAGE 1 <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( <br />) CM ( ) UNKNOWN <br />B. <br />t ) 01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />IC. <br />(X) 01 <br />DOUBLE WALLED ( ) 02 SINGLE WALLED t ) 03 LINED <br />ID. <br />( ) 01 <br />CARBON STEEL t ) 02 STAINLESS STEEL (X) 03 FIBERGLASS ( ) 04 <br />POLYVINYL CHLORIDE l ) 05 CONCRETE <br />( ) <br />06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE <br />( ) 10 NON-METALLIC <br />( ) 12 <br />UNKNOWN ( l 13 OTHER: <br />HSC04-07^185 <br />n <br />C7 <br />PAGE 1 <br />