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f <br /> STATE ID NUMBER 00000064653003 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT l ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATSON,INDZVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CAL TRANS I( ) 01 FEB ( ) 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS CITY STATE - - ZIP - <br /> 1976 E. CHARTER WAY <br /> __]ST CA 95205 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> TRACY MS JESSE RAINS <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 24155 S. CORRAL HOLLOW RD. <br /> CITY COUNTY ZIP <br /> TRACY SAN JOAQUIN 95376 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 24155 S. CORRAL HOLLOW R0. TRACY CA 95376 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-835-6779 ( ) 01 GASOLINE STATION (X) 02 OTHER MAINTENANCE STATION <br /> NUMBER OF CONTAIN EPS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 4 <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 /> WELLS. A.D. 209-948-7300 G. HOUSTON 209-874-3241 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (XI 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 305-8 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS (X) 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 f ) 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> I l <br /> 01 UNLEADED f 1 02 REGULAR [ ) 03 PREMIUM ( ) 04 DIESEL ( ! 05 WASTE OIL (X) 06 OTHER UNKNOWN <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( 1 CM (XI UNKNOWN <br /> S. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. l ) Ol DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL f 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS [ ) 04 POLYVINYL CHLORIDE f 1 OS CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (07/03/87) PAGE 1 <br /> OF KGR <br /> __...._..... . --"""-. -..-.. ... .,... �.., ..r ...,,,�..,,.. ,... �, <br /> STORED STORED <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> l ) Ol ( ) 02 ( ) 03 <br /> f ) O1 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> f l Ol ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 ( ) 03 <br /> • CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE( I5 TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT I0 R <br /> ( ) 01 YES f ) 02 NO <br /> • HSC04-070185 (07/03/87) PAGE 2 <br />