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• • STATE ID NUMBER 00000 � Y <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> UCr 01 NEW PERMIT ( l 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> !*"T-02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> N.AME(CORPORATiON,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> SAN JOAQUIN COUNTY RIGS ( l 01 FED ( ) 02 STATE 04V 03 LOCAL <br /> --] <br /> STREET ADDRESS �/ CITY STATE ZIP <br /> Z <br /> E, l.Q"eC Sy,. STOCKTON CA 952 <br /> II FACILITY <br /> FACILITY NAME c50.11 JCXL4t((,(r, co- DEALER/FOREMAN/SU�P.}ERVISOR ] <br /> STREET ADDRESS NEAREST CROSS STREET <br /> t=. R *' glia s A ve . <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95201 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P.O. BOX 1810 STOCKTON CA 95201 <br /> PHONE W/ARE.A CODE TYPEOF B ✓ <br /> USINESS / <br /> 209-944-2291 ( ) O1 GASOLINE STATION (X) 32 OTHER , ' <br /> NUMBER. OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 5 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AP.EA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> 'Pffit LA PIESTO 209-944-2291 ltntols�2�er4_16919Y01 2�f� <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER S <br /> B. MANUFACTURER (IF APPROPRIATE): UNKNOWN YEAR MFG: YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS (X) UNKNOWN JE. DOES THE CONTAINER STORE: ( 1 01 WASTE fX, n2 PRODUCT <br /> F. DOES THE CONTAINERSTOREMOTOR VEHICLE FUEL OR WASTE OIL ? E ) 01 YES V�o I= NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( 051WASTE OIL ( l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: [ ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) 02 NON-VAULTED ( 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED LKI 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( l 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( l 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE C ) 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> KSC04-070185 (10/18/85) PAGE 1 <br />