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STATE ID NUMBER 00000018336003 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> POP O1NEW3FRMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 7 09 DELETE FROM FILE (NO FEE) <br /> ( ] 02 NDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAM!(CORFORATION.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. ESCALDN 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 BELLOTA RD. LONE TREE ROAD <br /> CITY COUNTY ZIP <br /> ESCALON SAN JOAQUIN 95320 <br /> MAILING ADDRESS CITYSTATE ZIP <br /> 15658 S. ESCALON BELLOTA ROAD ESCALON CA 95320 <br /> PHONE W/AREA CODE TYPEOF BUSINESS <br /> 209-838-7002 ( ) 01 GASOLINE STATION (X) 02 OTHER TRUCKING FIRM <br /> NUMBER OF CONTAINERS RURAL AREAS ONLYTOWNSHIP RANGE SECTION <br /> 3 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAM!(LAST NAME FIRST) AND PHONE W/ARCA CODE <br /> DERICKSON( DAVID 209-838-7002 VID 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 3 <br /> S. MANUFACTURER (IF APPROPRIATE): MODESTO TANK YEAR MFG: 1975 C. YEAR INSTALLED 1975 l ) UNKNOWN <br /> D. CONTAINER CAPACITY: 2000 GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: (X) 01 WASTE f ] 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 ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL (X) 05 WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 3/16 ( ) GAUGE (X) INCHES ( ) CM ( ) UNKNOWN <br /> B. ( l 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED (X) 02 SINGLE WALLED 1 ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( 1 02 STAINLESS STEEL [ l 03 FIBERGLASS [ 1 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> f ) 06 ALUMINIM [ ) 07 STEEL CLAD f ) 08 BRONZE f l 09 COMPOSITE [ ) 10 NON-METALLIC <br /> l ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />