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r <br /> • • <br /> STATE ID NUMBER 00000016430003 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> t�J O1 NEW PERMIT ( l 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ' jl 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COP.POP.ATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> PACIFIC BELL ( ) 01 FED ( l 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS,57u �w I O Avo/�f f' k O� CITY � �� CA <br /> ATE ZI <br /> II FACILITY .I <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> PACIFIC BELL (UE-042) �!�`7� E.J.KOEHLER <br /> STP.EET ADDRESS NEAREST CROSS STREET <br /> 345 N. SAN JOAQUIN <br /> CITY COUNTY ZIP <br /> STOCKTON }� SAN JOAQUIN 95202 <br /> MAILING ADDRESS JbIx7 (c.TN6 `/ CITY STATE ZIP <br /> _ — (:A o�lT7 <br /> PHONE W/APEA CODE TYPE OF B SINESS <br /> 415-54e-&M a- <br /> 1.-� ( ) 01 GASOLINE STATION (X) 02 OTHER PHONE CO. <br /> NUMBER OF CCNTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 5 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: N:AME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST; AND PHONE W/AREA CODE <br /> EMERGENCY CONTROL CENTER 415-54�-�rtr41 $p'�'�f 7�"7? EMERGENCY CONTROL CENTER 415-5t=468 �?l <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( l 04 OTHER: CONTAINER NUMBER 0-67-25K01 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1967 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 25000 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 /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL ( l 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: t ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED 4:�_02 SINGLE WALLED ( l 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ) 06 ALUMINUM ( l 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( } 10 NON-METALLIC <br /> 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />