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�we <br /> STATE ID NUMBER 00000023077002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( l 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED - ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 102 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIGUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> SAN JOAQUIN COUNTY ( ) 01 FED [ ) 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 222 E. WEBER STOCKTON CA 95202 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> AGRICULTURAL COMMISSIONER'S OF MARY JENSEN <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 503 E. 10TH MACARTHUR <br /> CITY COUNTY ZIP <br /> TRACY SAN JOAQUIN 95376 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 503 E. 10TH TRACY CA 19.5376 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> .209-835-5903 ( ) 01 GASOLINE STATION (X) 02 OTHER COUNTY AGENCY <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 3 <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/ARCA CODE <br /> COUNTY OFFICE OF EMERGENC 209-944-2111 - - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER T-2 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 1000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: f ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( l 01 YES (X) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( } 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ] 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: l ) GAUGE ( ] INCHES f 1 CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( 1 02 SINGLE WALLED f ) 03 LINED <br /> D. ( ) 01 CARBON STEEL [ ] 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ] 04 POLYVINYL CHLORIDE ( 105 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD f ] 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />