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0 <br />0 STATE IO NUMBER 00000006224003 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />01 N W ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 3 09 DELETE FROM FILE (NO FEE) <br />") 2`E) I PERMIT ( l 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAME(CORPORATION,INOIVIDUAL OR PUBLIC AGENCY) <br />(X) 01 TANK ( ) 04 OTHER: <br />PUBLIC AGENCY ONLY <br />QUIK STOP MARKETS IN; <br />QUIK STOP #120 <br />t ) 01 FED t ) 02 STATE ( ) 03 LOCAL <br />STPEET A.ODP,ESS <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 />OEALER/FOREMAN/SUPERVISOR <br />CONTAINER <br />QUIK STOP #120 <br />B. <br />MANUFACTURER (IF APPROPRIATE): XERXES <br />YEAR MFG: <br />STREET ADDRESS <br />INSTALLED 1983 t ) UNKNOWN <br />NEAREST CROSS STREET <br />CONTAINER CAPACITY: 8000 GALLONS ( <br />9321 N. THORNTON RD <br />JE. DOES THE CONTAINER STORE: ( <br />WAGNER HEIGHTS <br />F. <br />CITY <br />FUEL OR WASTE OIL ? (X) 01 YES E ) 02 NO <br />PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL <br />COUNTY <br />ZIP <br />STOCKTON <br />SAN JOAQUIN <br />95207 <br />MAILING ADDRESS <br />CZTY <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 />(X) 01 GASOLINE STATION t ) 02 OTHER <br />NUMBER. OF CONTAINERS <br />RURAL AREAS ONLY :TOWNSHIP <br />RANGE <br />SECTION <br />4 <br />I11 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: N.AME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />rY -ttnv 7149 p_ <br />COM=PLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />"A. <br />(X) 01 TANK ( ) 04 OTHER: <br />) GAUGE t ) INCHES ( <br />CONTAINER <br />NUMBER 104 <br />B. <br />MANUFACTURER (IF APPROPRIATE): XERXES <br />YEAR MFG: <br />Tc.EAR <br />INSTALLED 1983 t ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: 8000 GALLONS ( <br />d UNKNOWN <br />JE. DOES THE CONTAINER STORE: ( <br />l 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE <br />( ) 01 UNLEADED ( ) 02 REGULAR (X) 03 <br />FUEL OR WASTE OIL ? (X) 01 YES E ) 02 NO <br />PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL <br />IF YES CHECK APPROPRIATE BOX(ES): <br />t ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: t <br />) GAUGE t ) INCHES ( <br />) CM (X) UNKNOWN <br />B..( <br />) 01 <br />VAULTED -( LOCATED IN AN UNDERGROUND VAULT) <br />(X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) 01 <br />DOUBLE WALLED (X) 02 SINGLE WALLED f )-03 <br />LINED - <br />D. <br />( ) 01 <br />( ) <br />( ) 12 <br />CARBON STEEL ( ) 02 STAINLESS STEEL (X) 03 FIBERGLASS t ) 04 <br />06 ALUMINUM f ) 07 STEEL CLAD ( D 08 BRONZE t ) 09 COMPOSITE <br />UNKNOWN ( ) 13 OTHER: <br />POLYVINYLCHLORIDE t ) 05 CONCRETE <br />f ) 10 NON-METALLIC <br />HSt04-070185 (10/18/85) <br />PAGE 1 <br />