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STATE ID NUMBER 00000030202002 <br />APPLICATION FOR PERMIT TO OPFRATF ILNnFRf;RniiNn STnPAr.F TANK <br />1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( l 09 DELETE FROM FILE (NO FEE) <br />l 02 CONDITIONAL PERMIT ( l 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />TRACY COMMUNITY MEMORIAL HOSPI ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />STREET ADDRESS CITY <br />STATE ZIP <br />1420 NORTH TRACY BOULEVARD TRACY ICA 95376 <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( ) 04 OTHER <br />DEALER/FOREMAN/SUPERVISOR <br />TRACY COMMUNITY MEMORIAL HOSPI <br />NUMBER 2 <br />CATHERINE MCGOWAN, ASST. ADMIN <br />STREET ADDRESS <br />YEAR MFG: 1977 <br />NEAREST CROSS STREET <br />1420 NORTH TRACY BOULEVARD <br />D. <br />EATON AVENUE <br />CITY <br />JE. DOES THE CONTAINER STORE: ( <br />COUNTY <br />ZIP <br />TRACY <br />FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO <br />PREMIUM (X) 04 DIESEL ( ) 05 WASTE OIL <br />SAN JOAQUIN <br />95376 <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />1420 NORTH TRACY BOULEVARD <br />TRACT <br />CA <br />95376 <br />PHONE W/AREA CODE <br />TYPE OF BUSINESS <br />209-835-1500 <br />( ) O1 GASOLINE STATION (X) 02 OTHER GENERAL HOSPITAL <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: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />`'' RK6QW 209-835-1500 MAINTENANCE MAN ON-CALL 209-835-1500 <br />N RRTInl, CL•huDC' <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 2 <br />B. <br />MANUFACTURER (IF APPROPRIATE): N/A <br />YEAR MFG: 1977 <br />C. <br />YEAR INSTALLED 1977 ( l UNKNOWN <br />D. <br />CONTAINER CAPACITY: 550 GALLONS ( <br />) UNKNOWN <br />JE. DOES THE CONTAINER STORE: ( <br />) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE <br />( ) 01 UNLEADED ( ) 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 />( ) <br />01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) <br />01 <br />DOUBLE WALLED (X) 02 SINGLE WALLED ( <br />) 03 LINED <br />D. <br />(X) <br />( <br />( l <br />01 <br />) <br />12 <br />CARBON STEEL ( ) 02 STAINLESS STEEL ( <br />06 ALUMINUM ( l 07 STEEL CLAD ( ) 08 <br />UNKNOWN ( ) 13 OTHER: <br />) 03 FIBERGLASS [ ) 04 <br />BRONZE ( ) 09 COMPOSITE <br />POLYVINYL CHLORIDE f ) 05 CONCRETE <br />( ) 10 NON-METALLIC <br />HSC04-070185 (10/18/85) <br />PAGE 1 <br />