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STATE ID NUMBER 00000016300001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> O1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 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 /> ROBERT & GREG ELLISON ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDFESS CITY STATE ZIP <br /> 4585 PARADISE OR TIBURON CA 94920 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> THE OUTLET <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1212 E. HARDING WAY <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95205 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 1212 E. HARDING WAY STOCKTON CA 95205 <br /> PHONE W%AREA CODE TYPE OF BUSINESS <br /> 209-465-6323 ( ) 01 GASOLINE STATION (X) 02 OTHER THRIFT STORE <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SCCTION <br /> 1 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/ARCA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> iYiiiiA'WY2MNK 209-465-6323 washoomsomm 2/"78-5i4g <br /> Ta S l; A._ M A Nor e1 -70 if-?k j tel' 7 7 7 <br /> �OMPLE E THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) Ol TANK ( ) 04 OTHER: CONTAINER NUMBER I <br /> B. MAHUFACTURER' (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1979 ( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 3000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE fX) 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 /> ( l <br /> 01 UNLEADED (X) 02 REGULAR f ) 03 PREMIUM [ ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( i GAUGE f ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. f ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> 0. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( l 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM f ) 07 STEEL CLAD ( 1 08 BRONZE [ ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/16/85) PAGE 1 <br />