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1-000 STATE I0 NUMBER 00000033591004 <br /> APPLICATION FOR PERMIT TO OPf ATE UNDERGROUND STOR GE TANK <br /> (AO O1 NEW PERMIT ( 1 05 RENEWED PERMIT (' 07 TANK CLOSED f 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT f l 06 AMENDED PERMIT ( 7 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIF AGENCY) PUBLIC AGENCY ONLY <br /> SALZEORNZA-DEPARTMENT OF CORK):C*(On$ ( ) 01 FED 01 02 STATE l ) 03 LOCAL <br /> STREET ADDRESS , CITY STATE ZIP <br /> P.O. BOX 714 SACRAMENTO CA 95803 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> DEUEL VOCATIONAL INSTITUTION C IEE OF PLANT OPERA7ion5 <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 23500 KASSON ROAD 1-5 <br /> CITY COUNTY ZIP <br /> TRACY SAN JOAQUIN 95376 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P.O. BOX 400 TRACY CA 95373'-OY920 <br /> PHONE W/AREA CODE - TYPE OF BUSINESS 7- <br /> 209-835-4141 �7Lt Q�yp Ol GASOLINE STATION Rd 02 OTHER ( wree O^DJ.:..(.� mtli4.�01% <br /> NUMBER O✓F CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <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 /> 209-835-4141 )-X+ 209-635-4141 FjV, -/ZY0 <br /> , COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE &V 02 PRODUCT <br /> F. DOE THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? OCf 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( l 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) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED Cd02 SINGLE WALLED [ ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE f 110 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> -.NW , wlmw� <br />