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_ <br /> APPLICATION FOR STATE ID <br /> PERMIT TO NUMBER <br /> / OPERATE UNDERGROUND STORAGE TANK <br /> �fXT OI`NEW PERMIT ( ) 05 RENEWED PERMIT <br /> 1_1 02-CONDITIONAL PERMIT f 1 06 AMENDED PERMIT ( J 07 TANK CLOSED <br /> 04 DELETE <br /> —._._----._—y f } 08 MINOR CHANGE (NO SURCHARGE) FROM ELLE (NO FEE <br /> ---—��_ <br /> I OWNER <br /> NAn"COPPOAATION.INCIVIDU4L <br /> OR PUBLIC AGENCY) - <br /> PORT OF STO <br /> - -' LIC AGENCY ONLY - <br /> src -_ <br /> [("1 01 ED <br /> ( I 02 STATE ( ) 03 LOCAL <br /> 2201 W. WASHINGTON ST. CITY - - -- ------ - <br /> --- STATE ZIP <br /> ST©c <br /> II FACILITY <br /> FACILITY NAME _ <br /> PORT OF STOC.KTON DEALER/FOPEMEN'SUPERVISOP = <br /> STCEE7 ACD^ESS <br /> 2201 W. WASHINGTON ST, NEAPEST CROSS STPEET <br /> CITY RD <br /> _STOCKTON' COUNTY ZIP <br /> MAILING AZI <br /> DDPESS <br /> P•0. B_ OX 2089 clrY 952 <br /> PHONE W•'AVEA CODE <br /> S I'OCKTOSTATE ZIP <br /> 2 0-9 TYPE CF 6USINESS <br /> —� ( 1 01 GASOLINE STATION (X ) 02 OTHER <br /> NUM6E1? CF CONTAINEcS <br /> 8 PUPAL AREAS ONLY : TOW.NSfiIP <br /> PANG£ <br /> -- SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAM,ErLAST NAGE FIPST! AND PHDNE W/An EA CODE <br /> TOLLINI F 1'i1SRK C. _ NICNTS: NAM✓!{ LAST "All FIRST) 4ND PHONE W✓AREA COD —� <br /> �._„� <br /> 209. 946- 246 SAME - _ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAIN — "�—` <br /> IV DESCRIPTION ER <br /> -S A.K.� 01 TABIC i 1 02 OTHER: '----- ----- - �� �- <br /> CONTAINER NUMBER <br /> J3. MANUFACTURER (IF APPROPRIATE J:UNKNOWN <br /> �� --- — --- YEAR MFG: C. YEAR INSTALLED 18Q ( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 12000 - <br /> -----_ NEP GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: f 1 01 WASTE (x) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? <br /> [ ► DI UNLEADED 02 REGULAR 1 1 03 PREMIUM i ) 04 DIESEL ( } t)5 WASTE OIL t } 06 OTHER <br /> -- ( 1 pI YES ( 1 02 IL IF YES CHECK APPROPRIATE SOX(fSl: <br /> V _CONTAINER CONSTRUCTION <br /> A. THICY,IIESS OF PP.IMARY CONTAINMENT` —'-- - 1 GAUGE ( ! RICHES i 1 CM 1 I UNKNOWN - - - <br /> B_i I 01 VAULTED (LOCATED IN AN UNOERGROU►JD VAULT) f ) 02 NON-VAULTED (� 03 UNKNOWN <br /> - ----- ------JC- 01 DOUBLE WALLED f ) 02 SINGLE WALLED f 103 LINfO <br /> fD. l 1 01 CARBON STEEL f l 02 STAINLESS STEEL f ! POLYVINYL--'1-HLORIDE - - <br /> fl r } °R °Lllr:rruy xSTEEL CLAD ( 1 0 03 FIBERGLASS ( 1 04 B Bnot'ZE 09 COMPOSITE 10 NON-METALLIC <br /> ( 1 6 1 ( 1 05 CONCRETE <br /> 12 UtIKNOW1l ( ) 13 OTHER. <br /> HSC04-070185 ----- --- -- -- -- — -- ----- <br /> PAGE I <br />