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0 • STATE ID NUMBER 00000016209003 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />01 NEW PERMIT f ) 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(CORPOP.ATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />`(3A g ( ) 01 FED ( ) 02 STATE [ ) 03 LOCAL <br />STREET ADDRESS CITY STATE ZIP <br />lvjl&-r W 4TTsKG SE .,pD �Q �� s STOCKTON ICA 95205 <br />II FACILITY <br />FACILITY NAME <br />:FiR <br />(X) 01 TANK ( ) <br />DEALER/FOREMAN/SUPERVISOR <br />L p <br />WESTERN wruAUGLE.-INC <br />MANUFACTURER (IF <br />APPROPRIATE): <br />YEAR MFG: <br />C. YEAR INSTALLED ( l UNKNOWN <br />STREET ADDRESS <br />CONTAINER CAPACITY: L0600 GALLONS ( <br />' <br />NEAREST CROSS STREET <br />F. <br />4100 EAST FREMONT <br />TORE MOTOR VEHICLE <br />02 REGULAR ( ) 03 <br />FUEL OR WASTE OIL ? ((e 01 YES ( ) 02 N0 IF YES CHECK APPROPRIATE BOX(ES): <br />PREMIUM t J 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br />ORO <br />CITY <br />COUNTY <br />ZIP <br />STOCKTON <br />SAN JOAQUIN <br />95205 <br />MAILING ADDRESS <br />CITY <br />JCTA <br />ATE <br />2IP <br />4190 EAST FREMONT <br />STOCKTON <br />95205 <br />PHONE W/AREA CODE <br />TYPE <br />OF BUSINESS <br />209-948-9771 <br />(X) <br />01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS <br />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: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />k1d821LQ-af�RK 6 209-948-9771 YOWKr-fflMt"!Cfl 209 �32.8338 y6 Z • Z 1 L <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( ) <br />04 OTHER: <br />) CM ( ) UNKNOWN <br />CONTAINER NUMBER 3 <br />B. <br />MANUFACTURER (IF <br />APPROPRIATE): <br />YEAR MFG: <br />C. YEAR INSTALLED ( l UNKNOWN <br />O. <br />CONTAINER CAPACITY: L0600 GALLONS ( <br />) UNKNOWN <br />E. DOES THE CONTAINER STORE: ( ) 01 WASTE O(r 02 PRODUCT <br />F. <br />DOES THE CONTAIN <br />( ) 01 UNLEADED <br />TORE MOTOR VEHICLE <br />02 REGULAR ( ) 03 <br />FUEL OR WASTE OIL ? ((e 01 YES ( ) 02 N0 IF YES CHECK APPROPRIATE BOX(ES): <br />PREMIUM t J 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br />�V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: <br />( ) GAUGE ( ) INCHES t <br />) CM ( ) UNKNOWN <br />B. <br />( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) 01 DOUBLE WALLED t ) 02 SINGLE WALLED ( <br />) 03 LINED <br />O. <br />( ) 01 CARBON STEEL t ) 02 STAINLESS STEEL ( <br />t ) 06 ALUMINUM ( l 07 STEEL CLAD t l 08 <br />( ) 12 UNKNOWN ( ) 13 OTHER: <br />) 03 FIBERGLASS ( ) 04 <br />BRONZE ( l 09 COMPOSITE <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( l 10 NON-METALLIC <br />HSC04-070185 (10/18/85) <br />PAGE 1 <br />