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Sloe STATE IO NUMBER 00000023953004 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE <br /> DELETE PROM FILE (NO FEE) <br /> 1 <br /> 01 NEW PERMIT t 105 RENEWED PERMIT ( 1 07 TANK CLOSED <br /> 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> PUBLIC AGENCY. ONLY <br /> WADOPESS <br /> IND IVIDUAL OR PUBLIC AGENCY) <br /> ( i O1 FED ( ) 02 STATE ( ) 03 LOCAL <br /> .A. STATE ZIP <br /> CITY TX 77210 <br /> HOUSTON <br /> E BLVD. <br /> II FACILITY <br /> DEALER/FOREMAN/SUPERVISOR <br /> FACILITY NAME RANDY VETESY <br /> EXXON SERVICE STATION <br /> NEAREST CROSS STREET <br /> STREET ADDRESS <br /> 3128 W. BENJAMIN HOLT ZIP <br /> COUNTY 95207 <br /> CITY SAN JOAGUIN <br /> STOCKTON STATE ZIP <br /> cxTY - <br /> MAILZNO ADDRESS $TOCKTON TX 95207 <br /> 3128 W. BENJAMIN HOLT <br /> TYPE OF BUSINESS <br /> PNCNE W/AREA CODE (X) 01 GASOLINE STATION ( 1 02 OTHER <br /> 209-478-6401 <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP <br /> RANGE SECTION <br /> 4 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM[(LAST NAME FIRST) AND PHONE W/ARCA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> HOFFMAN, S.D. 415-937-2991 <br /> HOFFMAN, S.D. 415-372-3361 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TAN)( ( 1 04 OTHER: CONTAINER NUMBER 4 <br /> S. MANUFACTURER (IF APPROPRIATE): UNKNOWN YEAR MFG: 1971 C. YEAR INSTALLED 1971 f I UNKNOWN <br /> 5-00 0. CONTAINER CAPACITY: 1009 GALLONS f 1 UNKNOWN E. DOES THE CONTAINER STORE: (X) 01 WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (XI 01 YES ( l 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED f ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL (X) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED f 1 03 LINED <br /> D. (X) 01 CARBON STEEL f 7 02 STAINLESS STEEL f ) 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM l ) 07 STEEL CLAD ( 1 08 BRONZE ( l 09 COMPOSITE f ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> . ASC04-070185 (10/18/85) PAGE 1 <br /> f. <br /> `/ <br />