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STATE 10 <br /> UMBER <br /> APPLICATION FOR PERMIT TO OP RATE�UNDERGROU• STORAGENTAN 00000010313002 <br /> [��Dl NEW PERMIT f 05 RENEWED PERMIT K02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT 07 TANK CLOSED <br /> 1 08 MINOR CHANGE (NO SURCHARGE) ) 09 DELETE FROM FILE (NO FEE) <br /> I OWNER <br /> "PACIFIC <br /> TION,INDIVIDUAL OR PUBLIC AGENCY) <br /> Y MIX INCCY ONLY <br /> SS ( 7 O1 FED t ) 02 STATE ( 1 03 LOCAL <br /> INC CITY <br /> SAN MATEO STATE ZIP <br /> C <br /> II FACILITY A 94401 <br /> FACILITY NAME <br /> PNEAUTT A_ � DEAL ER/FOREM SLIP ERVISOR �J <br /> STREET ADDRESS I LM1 ��5 OGII/•' <br /> 651 SO. f4Ae*&T"r1t' R. NEAREST CROSS SJRE EET <br /> CITY ,rl !/��� /b 411 <br /> TRACY COUNTY <br /> MAILING ADDRESS SAN JOAQUIN ZIP <br /> 651 SO.q xwmpw /l ac Alt-T t+u CITY 95376 <br /> SAME STATE ZIP <br /> PHONE W/AREA CODE CA 95376 <br /> 209-835-0770 TYPE OF BUSINESS <br /> NUMBER OF CONTAINERS ( ) 01 GASOLINE STATION (X) 02 OTHER READY MIX CONCRETE <br /> 2 RURAL AREAS ONLY : TOWNSHIP <br /> RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> 4���� NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> =(.✓N/ O 77 SAME 408-377-2587 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: <br /> CONTAINER NUMBER 2 <br /> B. MANUFACTURER fIF APPROPRIATE): <br /> YEAR MFG: C. YEAR INSTALLED <br /> (X) UNKNOWN <br /> 0. CONTAINER CAPACITY: 500 GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? <br /> ( ) O1 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL 0( )E05 WASTE 2No OILL fI) 06SOTHERK APPROPRIATE BOX(ES): <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( 1 CM (X) UNKNOWN <br /> B• ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br />�• ( 1 <br /> 01 DOUBLE WALLED ( 1 02 SINGLE WALLED f ) 03 LINED <br /> 01 CARBON STEEL f ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> (X) 12 UNKNOWN 13 OTHER:( 7 06 ALUMINUM f 7STEEL CLAD ( 1 O8 BRONZE f ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ) <br />�C04-070185 (10/18/851 <br /> PAGE 1 <br />