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t <br />STATE ID NUMBER 00000012661002 <br />APPLICATION FOR PERMIT rn nPvonro nunrnnn­ <br />01 NEW PERMIT [ ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED <br />Ti 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE)) 09 DELETE FROM FILE (NO FEE) <br />!�U^ICIJn <br />NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) <br />THE SOUTHLAND CORPORATION PUBLIC AGENCY ONLY <br />( ) 01 FED ( 7 02 STATE ( ) 03 LOCAL <br />STREET ADOPESS <br />5820 STONERIDGE MALL ROAD, 931 cziY STATE ZIP <br />PLEASANTON CA 94566 <br />II FACILITY <br />NAME <br />THICKNESS OF PRIMARY CONTAINMENT: <br />( ) GAUGE f ) INCHES <br />( ). CM (X) UNKNOWN <br />7 -FACILITY <br />ELEVEN FOOD STORE 2243-14117 <br />( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) <br />DEALER/FOREMAN/SUPERVISOR <br />( ) 03 UNKNOWN <br />C. <br />( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( <br />HARMOHAN SOHI <br />STREET ADDRESS <br />(XX)) 01 CARBON STEEL f 1 02 STAINLESS STEEL ( <br />) 03 FIBERGLASS ( ) 04 <br />POLYVINYL CHLORIDE f <br />2725 COUNTRY CLUB BLVD. <br />( ) 06 ALUMINUM ( 1 07 STEEL CLAD ( ) 08 <br />( ) <br />NEAREST CROSS STREET <br />) 05 CONCRETE <br />( ) 10 NON-METALLIC <br />12 UNKNOWN ( ) 13 OTHER: <br />INTERSTATE 5 <br />CITY <br />STOCKTON <br />COUNTY <br />ZIPSAN <br />JOAQUIN <br />95204 <br />MAILING ADDRESS <br />2937 VENEMAN ROAD <br />CITY <br />STATE <br />ZIP <br />MODESTO <br />CA <br />95356 <br />PHONE W/AREA CODE <br />TYPE OF BUSINESS <br />(X) 01 GASOLINE STATION ( 7 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLY : <br />TOWNSHIP <br />RANGE <br />3 <br />SECTION <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />,AYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />fOM EFAW 209-578-9716 TOM EFAW 209-527-0870 <br />ICOMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />IA. (X) 01 TANK ( ) 04 OTHER: <br />CONTAINER NUMBER -i4i1-2 <br />B. MANUFACTURER (IF APPROPRIATE): UNKNOWN YEAR MFG: C. YEAR INSTALLED 1976 ( ) UNKNOWN <br />D. CONTAINER CAPACITY: 100.00 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 />(X) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( 1 04 DIESEL ( ) 05 WASTE OIL f ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: <br />( ) GAUGE f ) INCHES <br />( ). CM (X) UNKNOWN <br />B. <br />( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) <br />(X) 02 NON -VAULTED <br />( ) 03 UNKNOWN <br />C. <br />( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( <br />1 03 LINED <br />0. <br />(XX)) 01 CARBON STEEL f 1 02 STAINLESS STEEL ( <br />) 03 FIBERGLASS ( ) 04 <br />POLYVINYL CHLORIDE f <br />( ) 06 ALUMINUM ( 1 07 STEEL CLAD ( ) 08 <br />( ) <br />BRONZE ( 1 09 COMPOSITE <br />) 05 CONCRETE <br />( ) 10 NON-METALLIC <br />12 UNKNOWN ( ) 13 OTHER: <br />iSC04-070).H5 (IAIIA/ACl <br />PAGE 1 <br />0 <br />