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STATE ID NUMBER 00000006693001 <br /> APPLICATION FOR PERMIT TO RGROUND STORAGE TANK <br /> ( ] O1 NEW PERMIT ( ) 05 RENEWED PERMITT NK CLO ( ) 09 DELETE FROM FILE (NO FEE. <br /> ( 1 02 LOND ITIONAL PERMIT f ) 06 AMENDED PERMIT ANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COP.PORATION,INDIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> WATERLOO MORADA FIRE DISTRICT ( ) 01 FED ( l 02 STATE X) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 6925 E. FOPPIANO LN STOCKTON CA 95212 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> WATERLOO MORADA FIRE DISTRICT TOM BENDER <br /> STREET ADDRESS NEAREST CROSS STREET <br /> ti <br /> CITY COUNTY ZIP <br /> 1. SAN JOAQUIN 95212 <br /> MA/LINO ADDRESS CITY STATE ZIP <br /> CA 95212 <br /> D <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-931-3107 f 1 01 GASOLINE STATION (X) 02 OTHER FIRE STATION <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 1 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: ME(LAST NA E FIRST) AND PHONE W/AREA CODE <br /> BENDER, TOM X30941& - SAME76-41 )K&K744 - ZO <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER I <br /> S. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1972 C. YEAR INSTALLED 1972 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 350 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) Ol 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 /> ( ) <br /> 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL ( 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1012 ( ) GAUGE (X) INCHES ( ) CM ( ) UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 7 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( 1 03 LINED <br /> 0. ( ) 01 CARBON STEEL f 1 02 STAINLESS STEEL f 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> ( ) 06 ALUMINUM (X) 07 STEEL CLAD ( ) 08 BRONZE ( l 09 COMPOSITE f 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> KSC04-070185 (1(1/18/85) PAGE 1 <br /> STATE ID NUMBER 00000006693001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP l 7 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( ) 06 TAR OR ASPHALT f 109 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: I ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE SOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( ) <br /> 01 VISUAL LCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> 1 ) 06 GROUND WATER MONITOR- IRT=S ( ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 O1 ( ) 02 ( ) 03 <br /> [ ) 01 ( ) 02 ( ) 03 <br /> f ) Ol ( ) 02 ( ) 03 <br /> f 1 01 ( ) 02 1 ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 Ol ( ) 02 ( 1 03 <br /> ( ) Ol ( ) 02 ( 1 03 <br />