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• STATE ID NUMBER 000.00062598004 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />Qjjjl NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />T—T) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />N.AME(CORPOPATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />CHEVRON U.S.A. INC. ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />STREET ADDRESS CITY STATE T94105 <br />575 MARKET SAN FRANCISCO CA <br />II FACILITY <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />MAINTENANCE DISPATCH 415-877-0244 - - <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />rQ 9127, <br />OTHER: <br />B. ( ) 01 <br />CONTAINER NUMBER 4 <br />FACILITY NAME <br />✓i <br />YEAR MFG: 1973 <br />C. YEAR INSTALLED 1973 ( ) UNKNOWN <br />DEALER/FOREMAN/SUPERVISOP <br />w -t= L(JtGd � <br />Vest C <br />LU no <br />f. DOES THE CONTAINER STORE:-(a�O1 WASTE (X) 02 PRODUCT <br />FE LTON, SHARON 0. <br />STREET ADDRESS <br />STORE MOTOR VEHICLE <br />l 02 ..REGULAR t l 03 <br />FUEL OR WASTE OIL ? .LU.01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />PREMIUM ( ) 04 DIESEL (. 05 WASTE OIL ( ) 06 OTHER <br />NEAREST CROSS STREET <br />2905 W. BENJAMIN HOLT <br />h'J- <br />CITY <br />COUNTY <br />ZIP <br />STOCKTON <br />SAN JOAQUIN <br />95207 <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />2905 W. BENJAMIN HOLT <br />STOCKTON <br />CA <br />95207 <br />PHONE W/AP.EA CODE <br />TYPE <br />OF BUSINESS <br />209-478-5555 <br />(X) <br />01 GASOLINE <br />STATION ( l 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS <br />ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />4 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />MAINTENANCE DISPATCH 415-877-0244 - - <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( ) 04 <br />OTHER: <br />B. ( ) 01 <br />CONTAINER NUMBER 4 <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: 1973 <br />C. YEAR INSTALLED 1973 ( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY <br />1000 -GALLONS( <br />) UNKNOWN <br />f. DOES THE CONTAINER STORE:-(a�O1 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER <br />l 01 UNLEADED ( <br />STORE MOTOR VEHICLE <br />l 02 ..REGULAR t l 03 <br />FUEL OR WASTE OIL ? .LU.01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />PREMIUM ( ) 04 DIESEL (. 05 WASTE OIL ( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. THICKNESS OF PRIMARY CONTAINMENT: 0000250 ( <br />) GAUGE ( l INCHES ( <br />) CM ( ) UNKNOWN <br />B. ( ) 01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) <br />(X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. ( ) 01 <br />DOUBLE WALLED (X) 02 SINGLE WALLED ( ) <br />03 LINED <br />D. (3 01 <br />J <br />t ) 12 <br />CARBON STEEL f ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS t ) 04 <br />06 ALUMINUM ( ) 07 STEEL CLAD t ) 08 BRONZE l 09 COMPOSITE <br />UNKNOWN ( ) 13 OTHER: <br />POLYVINYL CHLORIDE ( l 05 CONCRETE <br />( l 10 NON-METALLIC <br />HSC04-0701:85 (10/18/85) <br />PAGE 1 <br />