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STATE ID NUMBER 00000018775001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 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 /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> L— �� G I ( ) 01 FED ( ) 02 STATE 03 LOCAL <br /> STREET ADDRESS CITYSTATE ZIP <br /> 4511 PACIFIC AVE. STOCKTON CA 95207 <br /> II FACILITY <br /> FACILITY NAME 0, r.i6 j{ T DEALER/FOREMANiSUPERVISOR <br /> PACIFIC AVE. ARCO I I1: <br /> STREET AODP.ESS NEAREST CROSS STREET <br /> 4511 PACIFIC AVE ROSEMARIE <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95207 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 4511 PACIFIC AVE STOCKTON CA 95207 <br /> PHONE W/A.REA CODE TYPEOF BUSINESS <br /> 209-473-1177 (X) 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLYTOWNSHIP RANGE SECTION <br /> 5 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/ARE.A CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> 209-473-1177 — — <br /> --C-UMrLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> L <br /> A. (X) 01 TANK t ) 04 OTHER: CONTAINER NUMBER t)1 <br /> B. MANUFACTURER (IF APPROPRIATE): LINK YEAR MFG: C. YEAR INSTALLED ( ) UNKNOWN <br /> II� <br /> D. CONTAINER CAPACITY: 12000 GALLONS ( l UNKNOWN JE. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> Fi DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( l INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON—VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( , 02 SINGLE WALLED ( ) 03 LINED <br /> D. l 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD t ) 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON—METALLIC <br /> ( ) 13 OTHER: <br /> a HSC64-070185 (10/28/85) PAGE 1 <br /> II� <br /> 1 <br />