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ft% STATE ID NUMBER 00000030202001 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />NEW PERMIT <br />( l 05 <br />RENEWED <br />PERMIT ( <br />) 07 <br />TANK CLOSED <br />( ) 09 DELETE FROM FILE (NO FEE) <br />CONDITIONAL PERMIT <br />(' �_02 <br />( ) 06 <br />AMENDED <br />PERMIT ( <br />) 08 <br />MINOR CHANGE <br />(NO SURCHARGE) <br />COUNTY <br />ZIP <br />TRACY <br />IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 06 OTHER <br />SAN JOAQUIN <br />95376 <br />MAILING ADDRESS <br />I OWNER <br />NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />TRACY COMMUNITY MEMORIAL HOSPI ( ) 01 FED ( l 02 STATE ( ) 03 LOCAL <br />STREET ADDRESS CITY STATE ZIP <br />1420 NORTH TRACY BOULEVARD TRACY ICA 95376 <br />II FACILITY <br />FACILITY NAME <br />NAME(LAST NAME <br />DEALER/FOREMAN/SUPERVISOR <br />TRACY COMMUNITY MEMORIAL HOSPI <br />NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />CATHERINE.MCGOWAN, ASST. ADMIN <br />STREET ADDRESS <br />209-835-1500 <br />NEAREST CROSS STREET <br />1420 NORTH TRACY BOULEVARD <br />hp -11 <br />EATON AVENUE <br />CITY <br />) 01 WASTE (X) 02 PRODUCT <br />COUNTY <br />ZIP <br />TRACY <br />IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 06 OTHER <br />SAN JOAQUIN <br />95376 <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />1420 NORTH TRACY BOULEVARD <br />TRACY <br />CA <br />95376 <br />PHONE W/AREA CODE <br />TYPE OF BUSINISS <br />209-835-1500 <br />( ) 01 GASOLNE STATION (X) 02 OTHER GENERAL HOSPITAL <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLYTOWNSHIP <br />RANGE <br />SECTION <br />3 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />AYS: <br />NAME(LAST NAME <br />FIRST) AND PHONE W/AREA CODE <br />CONTAINER NUMBER 1 <br />NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />MANUFACTURER (IF APPROPRIATE): N/A <br />YEAR MFG: 1977 <br />209-835-1500 <br />YEAR INSTALLED 1977 ( ) UNKNOWN <br />MAINTENANCE MAN ON-CALL 209-835-1500 <br />hp -11 <br />14 ) CLftuW <br />E. DOES THE CONTAINER STORE: ( <br />) 01 WASTE (X) 02 PRODUCT <br />GUMF'LETE THE FULLUWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( ) 04 OTHER: <br />( ) GAUGE ( ) INCHES ( <br />CONTAINER NUMBER 1 <br />B. <br />MANUFACTURER (IF APPROPRIATE): N/A <br />YEAR MFG: 1977 <br />C. <br />YEAR INSTALLED 1977 ( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: 5000 GALLONS ( <br />) UNKNOWN <br />E. DOES THE CONTAINER STORE: ( <br />) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE <br />( l 01 UNLEADED ( l 02 REGULAR ( ) 03 <br />FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO <br />PREMIUM (X) 04 DIESEL [ ) 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 (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 ( <br />) 03 LINED <br />D. <br />(X) 01 <br />( ) <br />( ) 12 <br />CARBON STEEL ( ) 02 STAINLESS STEEL ( <br />06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 <br />UNKNOWN ( ) 13 OTHER: <br />) 03 FIBERGLASS ( ) 04 <br />BRONZE ( ) 09 COMPOSITE <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 10 NON-METALLIC <br />HSC04-070185 (10/18/85) <br />PAGE 1. <br />