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STATE ID NUMBER 00000014862002 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />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 />OWNER <br />NAME(CORPORATION,INDIV UAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />WEST ERN- 0• L ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />STREET ADDRESS CITY STATE ZIP <br />1210 E. HAMMER LN. STOCKTON ICA 95210 <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( ) 04 OTHER: <br />DEALER/FOREMAN/SUPERVISOR- <br />CONTAINER NUMBER 2 <br />HAMMER LANE BEACON <br />MANUFACTURER (IF APPROPRIATE): ARROW <br />YEAR MFG: 1979 <br />C. <br />STREET ADDRESS <br />D. <br />NEAREST CROSS STREET <br />E. DOES THE <br />1210 E. HAMMER LN <br />) 01 WASTE (X) 02 PRODUCT <br />KATHLEEN <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) <br />(X) A UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL <br />CITY <br />IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 06 OTHER <br />COUNTY <br />ZIP <br />STOCKTON <br />SAN JOAQUIN <br />95210 <br />MAILSNG ADDRESS <br />CIT <br />STATE <br />ZIP <br />1210 E. HAMMER LN <br />STOCKTON <br />CA <br />95210 <br />PHONE W/AP.EA CODE <br />TYPE OF BUSINESS <br />209-477-136- <br />(Xl 01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER OF CONTAINERSRURAL <br />AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />4 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAME(LAST NAME FIRST) AN HONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />209- <br />Cott�OMPL <br />E THE FOLLOWING ON A SEPAR FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( ) 04 OTHER: <br />) CM ( ) UNKNOWN <br />CONTAINER NUMBER 2 <br />B. <br />MANUFACTURER (IF APPROPRIATE): ARROW <br />YEAR MFG: 1979 <br />C. <br />YEAR INSTALLED 1980 ( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: 10000 GALLONS t l UNKNOWN <br />E. DOES THE <br />CONTAINER STORE: ( <br />) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) <br />(X) A UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL <br />01 YES ( ) 02 NO <br />( ) QS WASTE OIL <br />IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS Of PRIMARY CONTAINMENT: 1/4 ( ) GAUGE (X) INCHES ( <br />) CM ( ) UNKNOWN <br />B. <br />( ) 01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) 01 <br />DOUBLE WALLED (X) 02 SINGLE WALLED ( l 03 LINED <br />0. <br />(X) 01 <br />( ) <br />( ) 12 <br />CARBON STEEL ( ) 02 STAINLESS STEEL ( } 03 FIBERGLASS ( ) 04 <br />06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE <br />UNKNOWN ( ) 13 OTHER: <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( l 10 NON-METALLIC <br />HSC04-070185 (10/18/85) <br />10 0 <br />PAGE 1 <br />