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00 00 <br />STATE ID NUMBER 00000030202003 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />EW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE ENO FEE) <br />02 CONDITIONAL PERMIT ( l 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) <br />(X) 01 TANK ( ) 04 OTHER <br />PUBLIC AGENCY ONLY <br />TRACY COMMUNITY MEMORIAL HOSPI <br />B. <br />( ) 01 FED ( ) 02 STATE f l 03 LOCAL <br />STREET ADDRESS <br />CITY <br />STATE <br />ICA <br />ZIP <br />1420 NORTH TRACY BOULEVARD <br />TRACY <br />CITY <br />95376 <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( ) 04 OTHER <br />DEALER/FOREMAN/SUPERVISOR <br />TRACY COMMUNITY MEMORIAL HOSPI <br />B. <br />CATHERINE MCGOWAN, ASST. ADMIN <br />STREET ADDRESS <br />C. <br />NEAREST CROSS STREET <br />1420 NORTH TRACY BOULEVARD <br />CONTAINER CAPACITY: 1000 GALLONS ( ) UNKNOWN <br />EATON AVENUE <br />CITY <br />F. <br />COUNTY <br />ZIP <br />TRACY <br />SAN JOAQUIN <br />95376 <br />MAILING ADDRESS <br />) 03 FIBERGLASS ( ) 04 <br />CITY <br />STATE <br />ZIP <br />1420 NORTH TRACY BOULEVARD <br />BRONZE t ) 09 COMPOSITE <br />TRACY <br />CA <br />95376 <br />PHONE W/AREA CODE <br />TYPEOF BUSINESS <br />209-835-1500 <br />( ) 01 GASOLINE STATION (X) 02 OTHER GENERAL HOSPITAL <br />NUMBER. OF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNSMIP <br />RANGE <br />SECTION <br />3 <br />.III 24 HOUR EMERGENCY CONTACT PERSON <br />LAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />209-835-1500 MAINTENANCE MAN ON-CALL 209-835-1500 <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 NUMBER 3 <br />B. <br />MANUFACTURER (IF APPROPRIATE): N/A <br />YEAR MFG: 1974 <br />C. <br />YEAR INSTALLED 1974 ( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: 1000 GALLONS ( ) UNKNOWN <br />JE. DOES THE CONTAINER STORE: ( <br />) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO <br />( ) 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM ( ) 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 />( l 01 <br />VAULTED (LOCATED AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />S�IN <br />C. <br />( ) 01 <br />DOUBLE WALLED (V), 02 SINGLE WALLED ( <br />) 03 LINED <br />D. <br />(X) 01 <br />CARBON STEEL ( ) 02 STAINLESS STEEL ( <br />) 03 FIBERGLASS ( ) 04 <br />POLYVINYL CHLORIDE ( l 05 CONCRETE <br />( ) <br />06 ALUMINUM ( l 07 STEEL CLAD ( ) 08 <br />BRONZE t ) 09 COMPOSITE <br />t ) 10 NON-METALLIC <br />( ) 12 <br />UNKNOWN ( ) 13 OTHER: <br />HSC04-070185 (10/18/85) <br />PAGE 1 <br />