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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 01 NEW PERMIT ( ! 05 RENEWED PERMIT ( 1 07 TANK CLOSED ( 1 09 DELETE' FROM FILE (NO FEE) <br /> 1 1 O4 CONDITIONAL PERMIT 1 ? 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) -� <br /> I OWNER _ -- <br /> NAME(COPPORATION,INOIVIDUAL OR FUBLIC AGENCY) UAGENCY ONLY <br /> PORT OF STOCKTON -- -- FEO ( 102 STATE ( 1 03 LOCAL <br /> STCEET AO'79ESS CITY STATE ZIP <br /> 2201 W. WASHINGTON ST. STOCKTONCALIF. 95203 <br /> II FACILITY <br /> FACILITY N4ME _ DEALER/FOPEMEN/SUPERVISOP <br /> PO T OF STOCKTON r - <br /> STREET AOV�ESS NEAREST CROSS STREET <br /> 2201 W. WASHIN T N ST. RD. 13 & RD. "G" <br /> CITY .� COUNTY ZIP <br /> S TO ,TOA 952 <br /> -J�i MAILING ADDPESS CITY STATE ZIP <br /> P .O. BOX 2089 STOCKTON 952 <br /> PHONE WIAPEA CODE TYPE OF BUSINESS <br /> 209 9-46-0246 ( 1 01 GASOLINE STATION k 1 02 OTHER <br /> NU"EP CF CONTAIN€e5 RURAL AREAS ONLY TOWNSHIP RANGE SECTION — <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEILAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS! NAME(LAST NAME fIRSTI AND PHONE W/AREA CODE <br /> 'jQLLINu RK C. - - q, <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1 01 TANK ( 1 02 OTHER! CONTAINER NUMBER, <br /> B. MANUFACTURER (IF APPROPRIATE)- ZTNKNOG+TN YEAR MFG! �YEAPLLEDi qQ n (TI UNKNOWN <br /> IB. <br /> CONTAINER CAPACITYl1 2 GALLONS t 1 UNKNOWN E. DOES THE CONTAINER STORE: i I Oi WASTE�•� 2 P-RODUCT - <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? l 1 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE <br /> BOX(ES)- <br /> ( ) 0 UNLEADED ( 1 02 REGULAR ( 1 03 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL ( ) 06 OTHER -- <br /> V CONTAINER CONSTRUCTION <br /> A. THICYNESS OF PRIMARY CONTAINMENT! ( 1 GAUGE 1 ) INCHES ( 1 CM (X) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNOERGROUIID VAULT) ( ) 02 NON-VAULTED 1 03 UNKNOWN <br /> ,C_ ( 1 01 DOUBLE WALLED LLy� 02 SINGLE WALLED ( 1 03 LINED <br /> 0. ( l 01 CARBON STEEL 1 1 02 STAINLESS STEEL t 1 03 FI6ER'GLASS ( 1 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> - ( 1 06 ALUMINUM 17 STEEL CLAD ( 1 06 9R011ZE I 1 09 COMPOSITE ( 1 10 NDN-METALLIC <br /> ( 1 12 UNKNOWN i 1 13 O1-HER' <br /> - ----- --- - -------------- �--�_ ------- --- ---------- PAGE 1 <br /> H5CO4-0701135 <br />