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STATE ID NUMBER 00000051098003 <br />APPLICATION'FOR.PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />(>('-01 NEW PERMIT t ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED t ) 09 DELETE FROM FILE (NO FEE) <br />D 02 CONDITIONAL PERMIT t l 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />'I OWNER <br />NAME(ORPORATION,1INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />01 FED ( ) 02 STATE t ) 03 LOCAL <br />ZIP /ems/®gam <br />STREET ADDRESS CITY STATE <br />s- mar <br />II FACILITY <br />FACILITY NAME <br />{X) 01 TANK ( ) 04 OTHER:- <br />DEALER/FO MAN/SUPERVISOR <br />RICK'S CHEVRON SERVICE _ <br />NUMBER 3 <br />iC{C yt Pos <br />STREET .ADDRESS <br />YEAR MFG: <br />NEAREST CROSS STREET <br />8660 LOWER SACTO RD. <br />D. <br />PONCE DE LEON <br />CITY <br />CONTAINER STORE: { <br />COUNTY <br />ZIP <br />STOCKTON <br />01 YES ( ) 02 NO <br />t .} 05 WASTE OIL <br />SAN JOAQUIN <br />95210 <br />MAILING ADDRESS <br />CARBON STEEL ( <br />06 ALUMINUM i ) <br />UNKNOWN ( ) 13 <br />CITY <br />STATE <br />ZIP <br />8660 LOWER SACTO`RD. <br />STOCKTON <br />CA <br />95210 <br />PHONE W/AREA CODE <br />TYPE OF BUSINESS <br />209-477-0947 <br />(X) 01 GASOLINE STATION ( ) 02 OTHER <br />NJMSEP, OF CONTAINERS <br />RURAI,AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />3 <br />111 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 />GONZALES RICK 209-477-0947 GONZALES, RICK 209-952-2629 <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />{X) 01 TANK ( ) 04 OTHER:- <br />a GAUGE t ) INCHES ( <br />CONTAINER <br />NUMBER 3 <br />B. <br />MANUFACTURER (IF APPROPRIATE) <br />YEAR MFG: <br />C. <br />YEAR INSTALLED 1983 C } UNKNOWN <br />D. <br />CONTAINER CAPACITY: 10000 GALLONS t ) 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 'f ) 03 PREMIUM ( ) 04 DIESEL <br />01 YES ( ) 02 NO <br />t .} 05 WASTE OIL <br />IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF :PRIMARY CONTAINMENT: ( <br />a GAUGE t ) INCHES ( <br />) CM (X) UNKNOWN <br />B. <br />( ) <br />01 <br />VAULTED (LOCATED <br />IN AN UNDERGROUND VAULT) <br />(X) 02 NON—VAULTED ( <br />) 03 UNKNOWN <br />C. <br />t ) <br />01 <br />DOUBLE WALLED { <br />) 02 SINGLE WALLED ( ) <br />03 LINED <br />D. <br />( ) <br />(X) <br />01 <br />( ) <br />12 <br />CARBON STEEL ( <br />06 ALUMINUM i ) <br />UNKNOWN ( ) 13 <br />a 02 STAINLESS STEEL (Xa 03 FIBERGLASS ( J 04 <br />07 STEEL CLAD i ) 08 BRONZE ( } 09 COMPOSITE <br />OTHER:`_ <br />POLYVINYLCHLORIDE( ) 05 CONCRETE <br />( a 10 NON-METALLIC <br />HSC04-070185 (10/18/85) <br />PAGE 1 <br />