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STATE ID NUMBER 00000018336001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> LAj 01 NEW Pr MIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED f ) 09 DELETE FROM FILE (NO FEE) <br /> f 102 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> DERICKSON TRUCKING ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 15658 S. ESCALON BELLOTA RD. ESCALON CA 95320 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> DERICKSON TRUCKING DAVID DERICKSON <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 15658 S. ESCALON SELLOTA RD. LONE TREE ROAD <br /> CITY COUNTY ZIP <br /> ESCALON SAN JOAQUIN 95320 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 15658 S. ESCALON BELLOTA ROAD ESCALON CA 95320 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-838-7002 be ( ) 01 GASOLINE STATION (X) 02 OTHER TRUCKING FIRM <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 3 <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/APEA CODE <br /> DERICKSON, DAVID 209-838-7002 DERICKSON. DAVID 209-838-7002 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): MODESTO TANK YEAR MFG: 1969 C. YEAR INSTALLED 1969 ( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 12000 GALLONS l 1 UNKNOWN E.W0ES THE CONTAINER STORE: ( ) 01 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 /> ( ) 01 UNLEADED l ) 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL f ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS Of PRIMARY CONTAINMENT: 3/16 1 ) GAUGE (X) INCHES ( ) CM ( ) UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( ] 02 STAINLESS STEEL ( l 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE f 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> �I <br />