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\/ ~� STATE ID NUMBER 00000013774001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 1 NEW PERMIT ( ) 05 RENEWED PERMIT ( 1 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.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CIRCLE K CORPORATION ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE A2 850 850 <br /> 40 <br /> 4500 SOUTH 40TH STREET <br /> PHOENIX <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREM /SUPERVI OR <br /> CIRCLE K 01205 <br /> STREET ADDRESS <br /> 16470 CAMBRIDGE NEAREST CROSS STREET <br /> CITY COUNTY IIP <br /> LATHROP SAN JOAQUIN 95330 <br /> MAILING ADDRESS CITU <br /> STATE ZIP <br /> 953 <br /> 16470 CAMBRIDGE LATHROP AZ 95330 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 858-4116 (X) 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE 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 /> CP*w ^GKT33P1^ ftV-S3}-*540- <br /> W - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 10000 GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 <br /> 01 UNLEADED (X) 02 REGULAR f ) 03 PREMIUM ( ) 04 DIESEL l ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( l INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C:' ( ) 01 DOUBLE WALLED ( 1 02 SINGLE WALLED f 1 03 LINED <br /> D. (X) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS f l 04 POLYVINYL CHLORIDE ( ] 05 CONCRETE <br /> f ) 06 ALUMINUM ( ) 07 STEEL CLAD f 1 08 BRONZE ( 1 09 COMPOSITE ( ] 10 NON-METALLIC <br /> f l 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />