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i P 1*40 STATE ID NUMBER 00000037664002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f 1 01 NEW PERMIT ( ) 05 RENEWED PERMIT f ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT l ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> MIKE DEROUSI ( ) 01 FED f ) 02 STATE f ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 25054 E. ARTHUR ESCALON CA 95320 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> MIKE DEROUSI JIM DEROUSI <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 25056 E. ARTHUR BRENNAN RD <br /> CITY COUNTY ZIP <br /> ESCALON SAN JOAQUIN 95320 <br /> MAILING ADDRESS CITYSTATE ZIP <br /> 25056 E. ARTHUR ESCALON CA 95320 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-838-2410 ( ) 01 GASOLINE STATION (X) 02 OTHER AGRIC <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 2 13 9E 32 <br /> II1 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> _T10 <br /> IGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> DEROUSI MIKE 209-838-2410 DEROUSI MIKE 209-838-2410 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: CONTAINER NUMBER 2 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> 0. CONTAINER CAPACITY: 1000 GALLONS f ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE ( 1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES (X) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ' ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL f ) 05 WASTE OIL ( l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. f l 01 DOUBLE WALLED (X) 02 SINGLE WALLED [ ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( l 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD ( 1 08 BRONZE ( 109 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN t 1 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> 1 <br />