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STATE ID NUMBER 00000012403002 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />�O1 NEW PERMIT ( ) 05 RENEWED PERMIT ( l 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />IAME(COPPOR.ATION,INDIVIDU.AL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />'HE SOUTHLAND CORPORATION ( ) 01 FED ( ) 02 STATE f 1 03 LOCAL <br />TPEET ADDRESS FPLTEASANTON <br />Y STATE ZIP <br />,820 STONERIDGE MALL ROAD, #31 CA 94566 <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( ) 04 OTHER: <br />DEALER/FOREM.AN/SUFEP.VISOR <br />7 -ELEVEN FOOD STORE 2243-19976 <br />NUMBER 1.4446-2 <br />DENNIS & JAN ESENWEIN <br />STREET ADDRESS <br />YEAR MFG: <br />NEAREST CROSS STREET <br />1399 N. MAIN STREET <br />D. <br />NORTHGATE <br />C=TY <br />) 01 WASTE (X) 02 PRODUCT <br />COUNTY <br />ZIP <br />MANTECA <br />POLYVINYL CHLORIDE f ) 05 CONCRETE <br />( l 10 NON-METALLIC <br />SAN JOAQUIN <br />95336 <br />MAILING ADDRESS <br />__] <br />CITY <br />STATE <br />ZIP <br />2937 VENEMAN ROAD <br />MODESTO <br />CA <br />95356 <br />PHONE W/AREA CODE <br />TYPE OF BUSINESS <br />209 <br />(X) 01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER OF CONTAIN -ERS <br />RURAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />3 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />,AYS: NAME(LAST NAME FIRST) AND PHONE W/AP.EA CCDE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AP.EA CODE <br />'OM 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. <br />(X) 01 TANK ( ) 04 OTHER: <br />CONTAINMENT: ( ) GAUGE ( ) INCHES ( <br />CONTAINER <br />NUMBER 1.4446-2 <br />B. <br />MANUFACTURER (IF APPROPRIATE): UNKNOWN <br />YEAR MFG: <br />C. <br />YEAR INSTALLED 1977 ( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: 10000 GALLONS ( ) UNKNOWN <br />E. DOES THE CONTAINER STORE: ( <br />) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( l 02 NO <br />(X) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL <br />IF YES CHECK APPROPRIATE BOX(ES): <br />f ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY <br />CONTAINMENT: ( ) GAUGE ( ) INCHES ( <br />l 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 <br />(X) 02 SINGLE WALLED ( ) 03 LINED <br />D. <br />(X) 01 <br />( ) <br />( 1 12 <br />CARBON STEEL <br />06 ALUMINUM <br />UNKNOWN ( ) <br />( ) 02 STAINLESS STEEL ( l 03 FIBERGLASS ( ) 04 <br />( l 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE <br />13 OTHER: <br />POLYVINYL CHLORIDE f ) 05 CONCRETE <br />( l 10 NON-METALLIC <br />HSC04-070185 (10/18/85) PAGE 1 <br />