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STATE ID NUMBER 00000033591001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> kl�'O1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( l 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPOPATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CALIFORNIA DEPARTMENT OF CORR. ( 1 01 FED ( ) 02 STATE 1 ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> P.O. BOX 714 SACRAMENTO CA 95803 <br /> II FACILITY . <br /> FACILITY NAME DEALER/FOPEMAN/SUPERVISOR <br /> DEUEL VOCATIONAL INSTITUTION C EF OF PLANT OPERA <br /> STREET ADDRESS NEARlST CROSS ST EET <br /> 23500 KASSON ROAD 1-5 <br /> CITY <br /> COUNTY ZIP <br /> TRACT SAN JOAQUIN 95376 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P.O. BOX 400 TRACY CA 95376 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-835-4141 (X) 01 GASOLINE STATION f ) 02 OTHER <br /> NUMS!R OF CONTAINERS RVRAL AREpS ONLY TOWNSHIP RANGE SECTION <br /> 4 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAM! FIRST) AND PHONE W/AREA COD! �NIGMTS, (LAST NAME FIRST) AND PHONE W/ARE,!A CODE <br /> 209-835-4141 JZZJ -f.2-JQ209-835-4141 <br /> J <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBERee <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1984 l 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 2000 GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: f ) 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 /> f ) 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL f 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1/4 ( ) GAUGE (X) INCHES ( ) CM ( ) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED 06 02 SINGLE WALLED ( 1 03 LINED <br /> D. f ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 OS CONCRETE <br /> ( ) 06 ALUMINUM l ) 07 STEEL CLAD f 1 08 BRONZE ( ] 09 COMPOSITE ( ) 10 HON-METALLIC <br /> ( ) 12 UNKNOWN (X) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> 1 �� <br />