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` • • STATE ID NUMBER 00000035679002 <br /> APPLICATION FOR PERMIT TO OP ATE UNDERGROUND STORAGE TANK <br /> tk( , Ol NEW PERMIT ( ) 05 RENEWED PERMIT07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> &r) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT )4)-08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION,INDIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> WOODBRIDGE GOLF & COUNTRY CLUB ( ) 01 FED ( ) 0.2 STATE ( ) 03 LOCAL <br /> STREET ADDRESS - CITY STATE ZIP <br /> 800 E. WOODBRIDGE RO CA 95258 <br /> II FACILITY /� O / <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR fJ _ C n---ee�� <br /> WOODBRIDGE GOLF 3 COUNTRY CLUB . - T. zV� '_ <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 800 E. WOODBRIDGE ROAD LWR. SACTO. ROAD <br /> CITY COUNTY ZIP <br /> WOODBRIDGE SAN JOAQUIN 95258 <br /> MAILING ADDRESS CITYSTATE ZIP <br /> P.O. BOX 806 WOODBRIDGE CA 95258 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-368-6100 ( ) 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 NAME FIRST) AND PHONE W/AREA CODE <br /> R'ONA Io G�WSSL- 10.9-368-6103L_ T 2Q9-554.4553 <br /> nlO.. D a _ <br /> CO-MtP'CETE THE FOLLOWING ON A SEPARATE F RM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 81 TANK ( ) 04 OTHER: CONTAINER NUMBER 550 <br /> B. MANUFACTURER (IF APPROPRIATE): PERKINS WELDING YEAR MFG: 1984 C. YEAR INSTALLED 1984 ( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 550 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( I 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 /> ( l <br /> 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM f 1 04 DIESEL f ) 05 WASTE OIL (X) 06 OTHER PREMIX <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 10 (X) GAUGE f ) INCHES ( ) CM f ) UNKNOWN <br /> S. ( ) 01 VAULTED (LOCATED. IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGL€ WALLED ( ] 03 LINED <br /> 0. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 7 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( 7 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />