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STATE ID NUMBER 00000060123002 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />QG 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />("7 02 CONDITIONAL PERMIT ( l 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />M. ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />STREET ADDRESS CITY STAT ZIP <br />� <br />II FACILITY <br />ILI 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 />K4aDQII-VOff"00$07j- SAME <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( ) 04 OTHER: <br />(X) GAUGE ( ) INCHES ( <br />) CM ( ) UNKNOWN <br />FACILITY NAME <br />B. <br />DEA)R/FOREM N/ UPERVISOR <br />WELDING <br />(E�* A(N OX,*,,S <br />C. YEAR INSTALLED t?7 HE) UNKNOWN <br />NEAREST CROSS STREET <br />CONTAINER CAPACITY: 6000 GALLONS ( <br />s. ti: 1 (Avo <br />JE. DOES THE <br />STH <br />F. <br />CITY <br />FUEL OR WASTE OIL ? (X) <br />PREMIUM ( ) 04 DIESEL <br />COUNTY <br />) 03 FIBERGLASS ( ) 04 <br />BRONZE ( l 09 COMPOSITE <br />ZIP <br />STOCKTON <br />SAN JOAQUIN <br />95206 <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />1901 S. EL DORADO <br />STOCKTON <br />TX <br />95206 <br />PHONE W/AREA DE <br />TYPE OFBUSINESS <br />7 <br />(X) 01 GASOLINE STATION ( l 02 OTHER <br />NUMBER OF 0 AINERS <br />RURAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />ILI 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 />K4aDQII-VOff"00$07j- SAME <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( ) 04 OTHER: <br />(X) GAUGE ( ) INCHES ( <br />) CM ( ) UNKNOWN <br />CONTAINER NUMBER 2 <br />B. <br />MANUFACTURER (IF APPROPRIATE): MODERN <br />WELDING <br />YEAR MFG: <br />C. YEAR INSTALLED t?7 HE) UNKNOWN <br />D. <br />CONTAINER CAPACITY: 6000 GALLONS ( <br />) UNKNOWN <br />JE. DOES THE <br />CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE <br />(X) 01 UNLEADED ( ) 02 REGULAR HH 03 <br />FUEL OR WASTE OIL ? (X) <br />PREMIUM ( ) 04 DIESEL <br />01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 05 WASTE OIL f ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: 1/4 <br />(X) GAUGE ( ) INCHES ( <br />) CM ( ) UNKNOWN <br />B. <br />( ) <br />01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) <br />01 <br />DOUBLE WALLED (X) 02 SINGLE WALLED ( <br />) 03 LINED <br />D. <br />(X) <br />( <br />( ) <br />01 <br />) <br />12 <br />CARBON STEEL ( ) 02 STAINLESS STEEL ( <br />06 ALUMINUM ( J 07 STEEL CLAD ( 1 08 <br />UNKNOWN ( ) 13 OTHER: <br />) 03 FIBERGLASS ( ) 04 <br />BRONZE ( l 09 COMPOSITE <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 10 NON-METALLIC <br />HSC04-070185 (10/18/85) <br />PAGE 1 <br />