Laserfiche WebLink
• • STATE ID NUMBER 00000016209002 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />1l 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAME(CORPORATION.INDIVIOUAL OR PUBLIC AGENCY) <br />�/�E/Kf <br />PUBLIC AGENCY ONLY <br />KEN D ,Sja6fd/ j <br />B. <br />( ) 01 FED ( ) 02 STATE ( l 03 LOCAL <br />STREET ADDRESS // <br />12 D 1 9 /3*f ST <br />CITY <br />STATE <br />ZIP <br />1' i� • <br />STOCKTON <br />CA <br />95205 <br />II FACILITY <br />FACILITY NAME <br />WEST <br />�/�E/Kf <br />DEALER/FOREMAN/SUPERVISOR <br />^macK <br />51vel" <br />B. <br />_.LNC <br />YEAR MFG: <br />H <br />CAt13 R. <br />D. <br />61Q%i <br />STREET ADDRESS <br />F. <br />NEAREST CROSS STREET <br />D. <br />( ) 01 <br />( ) <br />( ) 12 <br />4100 EAST FR€MONT <br />1 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 <br />07 STEEL CLAD ( l 08 BRONZE ( ) 09 COMPOSITE <br />OTHER: <br />ORO <br />CITY <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 />209-948-9771 <br />(X) 01 GASOLINE STATION [ ) 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLY : JTOWNSHIP <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: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />HUK a ���(� 209-948-9771 YQRL .AARGW a� Ae&t309_&'?ft_M8 <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( ) 04 OTHER: <br />) CM ( ) UNKNOWN <br />CONTAINER NUMBER 2 <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />C. YEAR INSTALLED ( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: & dM GALLONS ( ) UNKNOWN <br />E. DOES THE CONTAINER STORE: ( ) 01 WASTE 0 02 PRODUCT <br />F. <br />OES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (W 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />( 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( <br />) CM ( ) UNKNOWN <br />B. <br />( ) 01 <br />VAULTED (LOCATED <br />IN AN UNDERGROUND VAULT) ( ) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) 01 <br />DOUBLE WALLED ( <br />l 02 SINGLE WALLED ( ) 03 LINED <br />D. <br />( ) 01 <br />( ) <br />( ) 12 <br />CARBON STEEL ( <br />06 ALUMINUM ( ) <br />UNKNOWN ( ) 13 <br />1 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 <br />07 STEEL CLAD ( l 08 BRONZE ( ) 09 COMPOSITE <br />OTHER: <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 10 NON-METALLIC <br />HSC0.4-070185 (10/18/85) <br />PAGE 1 <br />