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STATE ID NUMBER 00000013774003 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TAW CLOSED ( ) 09 DELETE FROM FILE (NO FEF) <br /> 02 CONDITIONAL PERMIT f 1 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 SIP <br /> 4500 SOUTH 40TH STREET PHOENIX AZ 85040 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMA SVPERVIS R <br /> CIRCLE K 01205 jxx_GHAeWft* <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 16470 CAMBRIDGE <br /> CITY COUNTY ZIP <br /> LATHROP SAN JOAQUIN 95330 <br /> MAZIING ADDRESS CITY STATE ZIP <br /> 16470 CAMBRIDGE LATHROP AZ 95330 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> -858-4136 (X) Ol GASOLINE STATION f ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP WA NGE 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 /> 4"A'WszK-ter a X"-Y7! - �f79q <br /> AvrG w <br /> PLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: CONTAINER NUMBER 3 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 4000 GALLONS ( l UNKNOWN E. DOES THE CONTAINER STORE: f ) 01 HASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) Ol YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f 7 <br /> 01 UNLEADED 1 1 02 REGULAR (X) 03 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> e <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( 1 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 ( 1 03 LINED <br /> D. (X) 01 CARBON STEEL ! ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ] 05 CONCRETE <br /> ( ) 06 ALUMINUM f ) 07 STEEL CLAD [ l 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />