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0 0 STATE ID NUMBER 00000006224001 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />() 01 NEW P° t ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />)ITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAM'E(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) <br />(X) 01 TANK { ) 04 OTHER: <br />PUBLIC AGENCY ONLY <br />QUIK STOP MARKETS INC <br />QUIK STOP 3)120 <br />( ) 01 FED t ) 02 STATE f ) 03 LOCAL <br />STREET ADDRESS <br />CITY <br />STATE <br />ZIP <br />4567 ENTERPRISE <br />FREMONT <br />CA <br />94538 <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK { ) 04 OTHER: <br />DEALER/FOREMAN/SUPERVISOR <br />CONTAINER NUMBER 102 <br />QUIK STOP 3)120 <br />MANUFACTURER (IF APPROPRIATE): XERXES <br />i.�(ef>�� � far <br />lie. <br />STREET ADDRESS <br />CONTAINER CAPACITY: 10000 GALLONS { l UNKNOWN <br />NEAREST CROSS STREET <br />CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br />9321 N. THORNTON RD <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) <br />( ) 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL <br />WAGNER HEIGHTS <br />CARBON STEEL t l 02 STAINLESS STEEL <br />06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 <br />UNKNOWN E ) 13 OTHER: ; <br />CITY <br />POLYVINYL CHLORIDE t ) 05 CONCRETE <br />( l 10 NON-METALLIC <br />COUNTY <br />ZIP <br />STOCKTON <br />SAN JOAQUIN <br />95207 <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />PO BOX 5745 <br />FREMONT <br />CA <br />94537 <br />PHONE W/APEA CODE <br />TYPE OF BUSINESS <br />209-478-7149 <br />(X) 01 GASOLINE STATION ( 1 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLY : <br />TOWNSHIP <br />RANGE <br />SECTION <br />4 <br />111 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 />COMPLETE THE FOLLOWING ON A SEPARATE FORM- FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK { ) 04 OTHER: <br />( ) GAUGE ( ) INCHES ( <br />CONTAINER NUMBER 102 <br />B. <br />MANUFACTURER (IF APPROPRIATE): XERXES <br />YEAR MFG= <br />C. YEAR INSTALLED 1983 t ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: 10000 GALLONS { l UNKNOWN <br />JE. DOES THE <br />CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) <br />( ) 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL <br />01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 05 WASTE OIL t ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: <br />( ) GAUGE ( ) INCHES ( <br />) CM (X) UNKNOWN <br />B. <br />( ) 01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) 01 <br />DOUBLE WALLED (X) 02 SINGLE WALLED t <br />) 03 LINED <br />D. <br />( ) 01 <br />( ) <br />( ) 12 <br />CARBON STEEL t l 02 STAINLESS STEEL <br />06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 <br />UNKNOWN E ) 13 OTHER: ; <br />(X) 03 FIBERGLASS ( ) 04 <br />BRONZE t ) 09 COMPOSITE <br />POLYVINYL CHLORIDE t ) 05 CONCRETE <br />( l 10 NON-METALLIC <br />HSC04-070185 (10/18/85) <br />PAGE 1 <br />