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• O�� • STATE ID NUMBER 00000057199001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 <br /> 01 NEW PERMIT ( 1 05 RENEWED PERMIT (w 07 TANK CLOSED Ix) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT (// ) 08 MINOR CHANGE (NO SURCHARG�EI <br /> I OWNER <br /> NAME(CORPCRATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> DOT/FEDERAL AVIATION ADMIN. ( ) 01 FED ( ) 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS 'CITY STATE ZIP <br /> 9624 KIEFER BLVD SACRAMENTO CA 95827 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> SCK-VORTAZ <br /> STREET ADDRESS NEAREST CROSS STREET <br /> PRESCOTT ROAD <br /> CITY COUNTY ZIP <br /> SAN JOAQUIN 95236 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 96524 KICKS SACRAMENTO CA 95627 <br /> PHONE W/.AREA CODE TYPE OF BUSINESS <br /> 000-000-0000 ( . ) 01 GASOLINE STATION f ) 02 OTHER <br /> RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> NUMBER CF CONTAINERS <br /> 1 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: N.AME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> 000-000-0000 SAME - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): UNK YEAR MFG: C. YEAR INSTALLED 1962 f ) UNKNOWN <br /> D. CONTAINER CAPACITY: 550 GALLONS f ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (XI 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 /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL t ) 05 WASTE OIL (X) 06 OTHER AVIATION GAS <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: UNK ( ) GAUGE ( 1 INCHES ( ) CM ( l 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 ( ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 103 FIBERGLASS f ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD f l 08 BRONZE ( ) 09 COMPOSITE f ) 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ). 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />