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STATE ID NUMBER 00000014862-004 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />(\kNEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( l 09 DELETE FROM FILE (NO FEE) <br />CTT) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAME(COP.POP.ATION.INDZVID L OR PUBL C AGE///N���CY) <br />PUBLIC AGENCY ONLY <br />I.IGGT p I T\11 •lIR RTIOt <br />`` <br />( l 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />STREET ADDRESS <br />CITY <br />TE <br />TSCTA <br />ZIP <br />1 <br />1210 E. HAMMER LN. <br />STOCKTON <br />95210 <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( ) 04 OTHER: <br />DEALER/FOREMAN/SUPERVISOR <br />CONTAINER <br />HAMMER LANE BEACON <br />B. <br />SPfifCER-CSEfi" <br />YEAR MFG: 1979 <br />STREET ADDRESS <br />YEAR INSTALLED 1980 ( l UNKNOWN <br />NEAREST CROSS STREET <br />CONTAINER CAPACITY: 10000 GALLONS ( ) UNKNOWN <br />1210 E. HAMMER LN <br />CONTAINER STORE: ( <br />KATHLEEN <br />F. <br />CITY <br />01 YES ( ) 02 NO <br />( ) 05 WASTE OIL <br />COUNTY <br />l 03 FIBERGLASS ( ) 04 <br />BRONZE ( ) 09 COMPOSITE <br />ZIP <br />STOCKTON <br />SAN JOAQUIN <br />95210 <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />1210 E. HAMMER LN <br />STOCKTON <br />CA <br />95210 <br />PHONE W/APEA CODE <br />TYPE OF BUSINESS <br />209-477-+13V <br />(X) O1 GASOLINE STATION ( 1 02 OTHER <br />NUMBEROF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />4 <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 />RRW.....E., ..SE.. 209-4�-ii36- (( 7'? 7t � - 2.09 -95't -1z m—, � L� c�1�� <br />THE FOLLOWING ON A SEPAR <br />IV DESCRIPTION <br />EACH CONTAINER <br />A. <br />(X) 01 TANK ( ) 04 OTHER: <br />CONTAINMENT: 1/4 <br />CONTAINER <br />NUMBER 4 <br />B. <br />MANUFACTURER (IF APPROPRIATE): ARROW <br />YEAR MFG: 1979 <br />C. <br />YEAR INSTALLED 1980 ( l UNKNOWN <br />D. <br />CONTAINER CAPACITY: 10000 GALLONS ( ) UNKNOWN <br />JE. 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) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL <br />01 YES ( ) 02 NO <br />( ) 05 WASTE OIL <br />IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 06 OTHER, <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY <br />CONTAINMENT: 1/4 <br />( ) GAUGE (X) INCHES ( <br />) CM ( ) UNKNOWN <br />B. <br />( ) <br />01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) <br />01 DOUBLE WALLED <br />(X) 02 SINGLE WALLED ( <br />l 03 LINED <br />D. <br />(X) <br />t <br />( ) <br />01 CARBON STEEL <br />) 06 ALUMINUM <br />12 UNKNOWN ( ) <br />( ) 02 STAINLESS STEEL ( <br />( 1 07 STEEL CLAD ( 108 <br />13 OTHER: <br />l 03 FIBERGLASS ( ) 04 <br />BRONZE ( ) 09 COMPOSITE <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 10 NON-METALLIC <br />HSC04-070185 (10/18/85) <br />PAGE 1 <br />