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• • STATE ID NUMBER 00000057864001 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />01 NEW PERMIT ( l 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />( ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />(X) 01 TANK ( ) 04 OTHER: <br />( } GAUGE ( ) INCHES ( <br />DEALER/FOREMAN/SUPERVISO <br />NUMBER 1 <br />PACIFIC BELL (UE-058)TRACC411E.J.KOEHLER <br />NAME(COP.PCR.ATION,INDIVIDUAL OR PUBLIC AGENCY) <br />YEAR MFG: <br />PUBLIC AGENCY <br />ONLY <br />STPEET ADDRESS <br />CONTAINER CAPACITY: 1500 GALLONS ( l UNKNOWN <br />PACIFIC BELL <br />NEAREST CROSS STREET <br />F. <br />( ) 01 FED ( <br />) 02 STATE <br />( ) 03 LOCAL <br />POLYVINYL CHLORIDE f l 05 CONCRETE <br />STREET ADDRESS <br />CITY <br />CITY <br />( l 10 NON-METALLIC <br />STATE <br />ZIP <br />ZIP <br />NN, ,/ <br />oo6/' Ak) <br />6N.�w,1?M*, ZLO50 <br />�`�T/u <br />CA <br />9 - Di <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( ) 04 OTHER: <br />( } GAUGE ( ) INCHES ( <br />DEALER/FOREMAN/SUPERVISO <br />NUMBER 1 <br />PACIFIC BELL (UE-058)TRACC411E.J.KOEHLER <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />-� <br />YEAR INSTALLED 1978 ( ) UNKNOWN <br />STPEET ADDRESS <br />CONTAINER CAPACITY: 1500 GALLONS ( l UNKNOWN <br />JE. DOES THE CONTAINER STORE: ( <br />NEAREST CROSS STREET <br />F. <br />10 EAST 12TH STREET <br />IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 06 OTHER <br />) 03 FIBERGLASS ( T 04 <br />POLYVINYL CHLORIDE f l 05 CONCRETE <br />CITY <br />BRONZE ( ) 09 COMPOSITE <br />( l 10 NON-METALLIC <br />COUNTY <br />( ) 12 UNKNOWN ( ) 13 OTHER: <br />ZIP <br />TRACY <br />SAN JOAQUIN <br />95376 <br />MAILIN^v ADDRESSh� <br />CITY <br />STATE <br />I�TC�G�Tl.t� <br />ZIP <br />Oe <br />l <br />Q,9- <br />CA <br />q <br />PHONE W/AP.EA CODE <br />TYPE OFBUSINESS <br />415-342- &:P% �5 r <br />( ) 01 <br />GASOLINE STATION ( X ) 02 OTHER SIC 4800 <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLY : <br />TOWNSHIP <br />RANGE <br />SECTION <br />1 <br />IIII 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODENIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />1/ <br />EMERGENCY CONTROL CENTER 415-;4e`7 7 7 SAME 9//5-L.2,9 <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( ) 04 OTHER: <br />( } GAUGE ( ) INCHES ( <br />CONTAINER <br />NUMBER 1 <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />C. <br />YEAR INSTALLED 1978 ( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: 1500 GALLONS ( l UNKNOWN <br />JE. 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 ( ) 02 NO <br />( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL ( ) 05 WASTE OIL <br />IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 06 OTHER <br />I V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: <br />( } GAUGE ( ) INCHES ( <br />) CM (X) UNKNOWN <br />B. <br />( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) 01 DOUBLE WALLED ( l 02 SINGLE WALLED ( <br />) 03 LINED <br />D. <br />(X) 01 CARBON STEEL ( l 02 STAINLESS STEEL ( <br />) 03 FIBERGLASS ( T 04 <br />POLYVINYL CHLORIDE f l 05 CONCRETE <br />( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 <br />BRONZE ( ) 09 COMPOSITE <br />( l 10 NON-METALLIC <br />( ) 12 UNKNOWN ( ) 13 OTHER: <br />HSC04-070185 (10/18/85) <br />PAGE 1 <br />