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0 <br />STATE ID NUMBER 00000062598002 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />( O1 NEW PERMIT ( l 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />2 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />N.AME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />CHEVRON U.S.A. INC. ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />STREET ADDRESS CITY STATE ZIP <br />575 MARKET SAN FRANCISCO CA 94105 <br />II FACILITY <br />FACILITY NAME ey q <br />ZZI:_ <br />OTHER: <br />DEALER/FOREM.AN/SUPERVISOR <br />CONTAINER NUMBER <br />9iteme <br />�,eVLgrFELTON, <br />MANUFACTURER (IF APPROPRIATE): <br />SHARON D. <br />YEAR MFG: 1973 <br />C. <br />YEAR INSTALLED 1973 ( ) UNKNOWN <br />) 03 FIBERGLASS ( ) 04 <br />POLYVINYL CHLORIDE t ) 05 CONCRETE <br />( ) 06 ALUMINUM <br />STREET ADDRESS <br />BRONZE ( ) 09 COMPOSITE <br />( l 10 NON-METALLIC <br />NEAREST CROSS STREET <br />CONTAINER CAPACITY: <br />2905 W. BENJAMIN HOLT <br />E. DOES THE CONTAINER STORE: ( <br />) 01 WASTE <br />p <br />F. <br />CITY <br />STORE MOTOR VEHICL€ FUEL OR WASTE OIL ? (-V-01 YES ( ) 02 NO <br />IF YES CHECK <br />COUNTY <br />ZIP <br />STOCKTON <br />) 04 DIE ( ) 05 WASTE OIL <br />( ) 06 OTHER <br />SAN JOAQUIN <br />95207 <br />MAILINGG ADDPESS <br />CITY <br />STATE <br />ZIP <br />2905, W. BENJAMIN HOLT <br />STOCKTON <br />CA <br />95207 <br />PHONE W/APIA CODE <br />TYPE OF BUSINESS <br />209-478-5555 <br />(X) 01 GASOLINE <br />STATION f ) 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLYTOWNSHIP <br />RANGE <br />SECTION <br />4 <br />I1I 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 ( l 04 <br />OTHER: <br />) CM ( ) UNKNOWN <br />CONTAINER NUMBER <br />) 03 UNKNOWN <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />) 03 LINED <br />YEAR MFG: 1973 <br />C. <br />YEAR INSTALLED 1973 ( ) UNKNOWN <br />) 03 FIBERGLASS ( ) 04 <br />POLYVINYL CHLORIDE t ) 05 CONCRETE <br />( ) 06 ALUMINUM <br />( l 07 STEEL CLAD ( ) 08 <br />BRONZE ( ) 09 COMPOSITE <br />( l 10 NON-METALLIC <br />D. <br />CONTAINER CAPACITY: <br />�SGLLONS ( ) UNKNOWN <br />E. DOES THE CONTAINER STORE: ( <br />) 01 WASTE <br />(X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER <br />STORE MOTOR VEHICL€ FUEL OR WASTE OIL ? (-V-01 YES ( ) 02 NO <br />IF YES CHECK <br />APPROPRIATE BOX(ES): <br />( l 01 UNLEADED ( <br />) 02 REGULAR 0d 03 PREMIUM ( <br />) 04 DIE ( ) 05 WASTE OIL <br />( ) 06 OTHER <br />V CONTAINER CONSTRUCTIO <br />A. THICKNESS OF PRIMARY <br />CONTAINMENT: 0000250 <br />( ) GAUGE ( l INCHES ( <br />) CM ( ) UNKNOWN <br />B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. ( ) 01 DOUBLE WALLED <br />(X) 02 SINGLE WALLED ( <br />) 03 LINED <br />D. J.Uj'1 CARBON STEEL <br />t ) 02 STAINLESS STEEL t <br />) 03 FIBERGLASS ( ) 04 <br />POLYVINYL CHLORIDE t ) 05 CONCRETE <br />( ) 06 ALUMINUM <br />( l 07 STEEL CLAD ( ) 08 <br />BRONZE ( ) 09 COMPOSITE <br />( l 10 NON-METALLIC <br />( l 12'UNKNOWN ( ) <br />13 OTHER: <br />HSC04-07.0I6S (10/18/85) <br />f <br />PAGE 1 <br />