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�� nN✓V �� STATE 10 NUMBER 00000024872003 <br /> APPLICATION FOR PERMIT TO OP RATE UNDERGROUND STORAGE TANK <br /> fY(]�1 NEW PERMIT ( l 05 RENEWED PERMIT TANK- ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT f OR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORAT:ON,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> SAN JOAQUIN COUNTY MOSQUITO AS ( ) 01 FED f ) 02 STATE = 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 5503 SOUTH AIRPORT WAY STOCKTON CA 95206 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> SAN JOAQUIN COUNTY MOSQUITO AB ( <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 5503 SOUTH AIRPORT WAY _ 'Frevlc_k camo <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95206 <br /> MAILING ADDPESS CITY STATE ZIP <br /> 5503 SOUTH AIRPORT WAY STOCKTON CA 95206 <br /> PHONE W/AREA CODE TYPE) OF BUSINESS <br /> 209-982-4675 f 01 GASOLINE STATION (X) 02 OTHER MOSQUITO ABATEMENT <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 6 <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 /> FIORI. JACK V. 209-982-4675 FIORI� JACK V. 209-368-9518 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. fX) 01 TANK f ) 04 OTHER: CONTAINER NUMBER IF3Y- <br /> S. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1968 ( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 1000 GALLONS ( ) 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 l ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL f l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( ) CM (X) UNKNOWN <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. f l 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( l 03 LINED <br /> D. rye) 01 CARBON STEEL l ) 02 STAINLESS STEEL f ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> [ 1 06 ALUMINUM (X) 07 STEEL CLAD f ) 08 BRONZE [ l 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> ASCG4-070185 (10/18/85) PAGE 1 <br /> 4 �w `\j <br />