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• • STATE ID NUMBER 00000018775002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( l 01 NEW PERMIT t l 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 /> E <br /> N.AME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> rte/_ V,/`''" ( l 01 FED ( ) 02 STATE 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 4511 PACIFIC AVE. STOCKTON CA 95207 <br /> II FACILITY <br /> FACILITY NAME I y` 1 /`�1 DEALER/FOREMAN/SUPERVISOR <br /> PACIFIC AVE. ARCO <br /> &EMl*WI b"N66846a- <br /> STREET ADDRESS 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 /> FIPHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-473-1177 (X1 01 GASOLINE STATION ( ) 02 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/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> 209-473-1177 - - <br /> OMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: CONTAINER NUMBER #2 <br /> B. MANUFACTURER (IF APPROPRIATE): UNK YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 12000 GALLONS ( ) UNKNOWN JE. 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 /> f ) 01 UNLEADED ( ) 02 REGULAR (X) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL t ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( I 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. 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ---'f—) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE t ) 09 COMPOSITE ( l 10 NON-METALLIC <br /> 4N! 16 WIKIIQWM-04 ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />