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STATE ID NUMBER 00000012403001 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />1 <br />01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 109 DELETE FROM FILE (NO FEE) <br />( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAME(CORPOP.ATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY 1 <br />THE SOUTHLAND CORPORATION ( ) 01 FED ( ) 02 STATE ( l 03 LOCAL <br />STREET ADDRESS CITY STATE ZIP <br />5820 STONERIDGE MALL ROAD, #31 PLEASANTON CA 94566 <br />II FACILITY <br />FACILITY NAME <br />THICKNESS OF PRIMARY CONTAINMENT: ( l GAUGE ( ) INCHES ( <br />DEALER/FOREM.AN/SUPERVISOR <br />B. <br />7 -ELEVEN FOOD STORE 2243-19976 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />DENNIS & JAN ESENWEIN <br />C. <br />STREET ADDRESS <br />DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br />NEAREST CROSS STREET <br />D. <br />1399 N. MAIN STREET <br />CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 <br />06 ALUMINUM t l 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE <br />UNKNOWN ( ) 13 OTHER: <br />NORTHGATE <br />CITY <br />COUNTY <br />ZIP <br />MANTECA <br />SAN JOAQUIN <br />95336 <br />MAILING ADDRESS <br />[MODT'ESTO <br />STATE <br />ZIP <br />2937 VENEMAN ROAD <br />CA <br />95356 <br />PHONE W/AP.EA CODE <br />TYPE OF BUSINESS <br />209 rev-�;-i� a'j=j,� <br />( X ) 01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER OF CONTAINERSRURAL <br />AREAS ONLY JTOWNSHIP <br />RANGE <br />SECTION <br />3 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CCDE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />TOM EFAW 209-578-9716 TOM EFAW 209-527-0870 <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. (X) 01 TANK ( ) 04 OTHER: 'CONTAINER NUMBER 19946-1 <br />B. MANUFACTURER (IF APPROPRIATE): UNKNOWN YEAR MFG: C. YEAR INSTALLED 1977 ( ) UNKNOWN <br />D. 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 />( ) <br />01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM f ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: ( l GAUGE ( ) INCHES ( <br />) CM (X) UNKNOWN <br />B. <br />( ) 01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) 01 <br />DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br />D. <br />(X) 01 <br />( ) <br />( ) 12 <br />CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 <br />06 ALUMINUM t l 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE <br />UNKNOWN ( ) 13 OTHER: <br />POLYVINYL CHLORIDE ( l 05 CONCRETE <br />( 110 NON-METALLIC <br />SC04-070185 (10/18/85) PAGE 1 <br />