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• STATE ID NUMBER 00000016209001 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FELE (NO FEE) <br />( 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAME(COP.FOP.ATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />KEN--t--A1t D ( ) 01 FED ( ) 02 STATE ( l 03 LOCAL <br />STREET ADDRESS CITY STATE ZIP <br />12 RD 511-1 S' r STOCKTON CA 95205 <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( ) 04 OTHER: <br />( ) GAUGE ( ) INCHES ( <br />DEALER/FOREMAN/SUPERVISOR <br />NUMBER 1 <br />WESn-* <br />T"^ <br />YEAR MFG: <br />"00960-*BRIFlAsit 31004 G <br />STREET ADDRESS <br />D. <br />CONTAINER CAPACITY: /40" GALLONS t ) UNKNOWN <br />NEAREST CROSS STREET <br />) 01 WASTE (X) 02 PRODUCT <br />4100 EAST FREMONT <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? V01 YES ( ) 02 NO <br />( ) 01 UNLEADED (, ` 02 REGULAR ( ) 03 PREMIUM VQ 04 DIE ( ) 05 WASTE OIL <br />IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 06 OTHER <br />ORO <br />) 02 STAINLESS STEEL ( <br />07 STEEL CLAD ( ) 08 <br />OTHER: <br />CITY <br />POLYVINYL CHLORIDE ( l 05 CONCRETE <br />( ) 10 NON-METALLIC <br />COUNTY <br />ZIP <br />STOCKTON <br />SAN JOAQUIN <br />95205 <br />MAILING AdDRESS <br />CITY <br />STATE <br />ZIP <br />4100 EAST FREMONT <br />STOCKTON <br />CA <br />95205 <br />PHONE W/AREA CODE <br />TYPE Of BUSINESS <br />209=948-9-771 r� <br />,!Z <br />(X) 01 GASOLINE STATION ( l 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />3 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAMEiIAST NAME FIRST) AND PHONE�%/AREA CODE �j <br />HA( @tB--YORK $, 249-�948�47�1 •S q YOR}l�iiltR9tU a • 6 Ew z 7 z i <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 <br />NUMBER 1 <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />C. <br />YEAR INSTALLED ( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: /40" GALLONS t ) UNKNOWN <br />E. DOES THE CONTAINER STORE: ( <br />) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? V01 YES ( ) 02 NO <br />( ) 01 UNLEADED (, ` 02 REGULAR ( ) 03 PREMIUM VQ 04 DIE ( ) 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 ( ) INCHES ( <br />) CM ( ) UNKNOWN <br />B. <br />( ) 01 <br />VAULTED (LOCATED <br />IN AN UNDERGROUND VAULT) t ) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) 01 <br />DOUBLE WALLED ( <br />1 02 SINGLE WALLED ( <br />) 03 LINED <br />D. <br />( ) 01 <br />( ) <br />( ) 12 <br />CARBON STEEL ( <br />06 ALUMINUM ( ) <br />UNKNOWN ( ) 13 <br />) 02 STAINLESS STEEL ( <br />07 STEEL CLAD ( ) 08 <br />OTHER: <br />l 03 FIBERGLASS ( ) 04 <br />BRONZE ( ) 09 COMPOSITE <br />POLYVINYL CHLORIDE ( l 05 CONCRETE <br />( ) 10 NON-METALLIC <br />HSC04-070185 (10/18/85) <br />0- 0 <br />PAGE 1 <br />