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STATE ID NUMBER 00000006224002 <br />APP! TrATTnN rnR P;:PMTT Tn nppPATF IDREnromQC)imn CTnPAciz TARN <br />0 ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED { ) 09 DELETE FROM FILE (NO FEE) <br />0 C N TIONAL PERMIT t ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGED <br />I OWNER <br />NAME(COP.FORATION,INJI.VIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />QUIK STOP MARKETS INC f ') 01 FED i l 02 STATE t ) 03 LOCAL <br />STREET ADDRESS CITY STATE ZIP <br />4567 ENTERPRISE FREMONT CA 94538 <br />IIFACILITY <br />FACILITY NAME <br />(X) 01 TANK` t ) 04 OTHER: <br />DEALER/FOREMAN LIP R ISOR <br />CONTAINER <br />QUIK STOP #20 <br />B. <br />rr <br />YEAR MFG: <br />STP?ET ADDRESS <br />INSTALLED 1983 t D UNKNOWN <br />NEAREST CROSS STREET <br />CONTAINER CAPACITY: 10000 GALLONS t ) UNKNOWN <br />9321 N. THORNTON RD <br />) 01 WASTE (X) 02 PRODUCT <br />WAGNER HEIGHTS <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( D 02 NO <br />(X) 01 :UNLEADED t ) 02 REGULAR ( D 03 PREMIUM t B 04 DIESEL E ) 05 WASTE OIL <br />CITY <br />POLYVINYL CHLORIDE t ) 05 CONCRETE <br />t D 10 NON-METALLIC <br />COUNTY <br />ZIP <br />STOCKTON <br />SAN JOAQUIN <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP' <br />PO BOX 5745 <br />FREMONT <br />CA <br />94537 <br />PHONE. W/AREA CODE <br />TYPE OF BUSINESS <br />209-478-7149 <br />tXD 01 GASOLINE STATION E } 02 OTHER <br />NUMBER QF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />4: <br />III 2.HOUR EMERGENCY CONTACT PERSON <br />DAYS: NA:ME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />y-. Y <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK` t ) 04 OTHER: <br />( ) GAUGE t ) INCHES ( <br />CONTAINER <br />NUMBER 103 <br />B. <br />MANUFACTURER (IF APPROPRIATE): XERXES <br />YEAR MFG: <br />=EAR <br />INSTALLED 1983 t D UNKNOWN <br />D. <br />CONTAINER CAPACITY: 10000 GALLONS t ) UNKNOWN <br />JE. DOES THE CONTAINER STORE: ( <br />) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( D 02 NO <br />(X) 01 :UNLEADED t ) 02 REGULAR ( D 03 PREMIUM t B 04 DIESEL E ) 05 WASTE OIL <br />IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: <br />( ) GAUGE t ) 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' E <br />) 03 LINED <br />D. <br />( } 01 <br />t ) <br />( } 12 <br />CARBON STEEL ( ) 02 STAINLESS STEEL <br />06 ALUMINUM t ) 07 STEEL CLAD ( ) 08 <br />UNKNOWN ( ) 13 OTHER: <br />(X) 03 FIBERGLASS ( ) 04 <br />BRONZE ( ) 09 COMPOSITE <br />POLYVINYL CHLORIDE t ) 05 CONCRETE <br />t D 10 NON-METALLIC <br />HSC04-070185 (10/18/85) PAGE 1 <br />