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1 <br /> • STATE ID NUMBER 00000063414002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (�#) 01 NEW PERMIT [ ] 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PEPHIT { ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPCPA.TICN,INIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ( ) 01 FED f 1 02 STATE ( l 03 LOCAL <br /> STREET ADOPESS CITY STATE ZT-P <br /> 1756 NO. WILSON WAY STOCKTON CA 95205 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMA 'SUPERVISOR <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1756 NO WILSON WAY BRADFORD <br /> CITY COUNTY ZIP <br /> STOCKTON 9 SAN JOAQUIN 95205 <br /> MAILING ADDRESS { ' CITY 'STATE ZIP <br /> -6 ` (, STOCKTON CA f5� j�Q <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-941-2264 (X) 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 2 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAT FIRST) AND PHONE W/AREA CODE <br /> RE)* be*e. � � 209-8 SAME <br /> COMPLETE THE FOLL014ING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK { 1 04 OTHER: CCNTAINER NUMBER 2 <br /> B. MANUFACTURER (IF APPROPRIATE): PERKINS YEAR MFG: 1972 C. YEAR INSTALLED 1972 { ) UNKNOWN <br /> 0. CONTAINER CAPACITY: 10000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 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 /> (X) 01 UNLEADED f ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1/4 ( ) GAUGE (X) INCHES ( ) CM ( ) UNKNOWN <br /> B. ( 1 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 /> 0. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS [ ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( 109 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />