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STATE I0 NUMBER 00000023438001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROU D STORAGE TANK <br /> 00 01 NEW PERMIT ( ) 05 RENEWED PERMIT f ) 07 TANK CLOSED I0 (� 4 ( 1 09 DELETE FROM FILE (NO FEE) <br /> ( 102 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT 08 INOR H E f O SURCHARGE) <br /> I OWNER <br /> NAMEICCRPCPATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> V <br /> CLEMENTS RURAL COUNTY FIRE PRO IrJ ;ct- f ) 01 FED f ) 02 STATE yO 03 LOCAL <br /> STR EE ADDRESS CITY STATE ZIP <br /> 18623'HWY 88 CLEMENTS CA 95227 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUP RVISOR <br /> CLEMENTS RURAL COUNTY FIRE PRO RATtNBEk-EH3ZF- p� �I <br /> STREET ADOP.ESS NEAREST CROSS STREET <br /> 18623 HWY 88 2ND STREET <br /> CITY COUNTY ZIP <br /> CLEMENTS - SAN JOAQUIN 95227 <br /> MAILING ADD41SS CITY STATE ZIP <br /> P.O. BOX 523 CLEMENTS CA 95227 <br /> PHONE W/AREA CODE TYPEOF BUSINESS <br /> 209-759-3"r'3'3?t ( ) 01 GASOLINE STATION (X) 02 OTHER FIRE STATION <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> Ae :2- 4N 8E 22 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMECLAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> ENGEL, RAY 209-759-3371 ENGEL, RAY 209-759-3371 <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): STKN, MANUFACTURING YEAR MFG: 1980C. YEAR INSTALLED 1980 ( 1 UNKNOWN <br /> s' <br /> D. CONTAINER CAPACITY: -73r GALLONS ( l UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WA '+ X) 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> ( l 01 UNLEADED (X) 02 REGULAR ( 1 03 PREMIUM 4 DIES f ) 05 WASTE OIL ( l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE f ) INCHES ( ) CM (XI UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( l 01 DOUBLE WALLED (X) 02 SINGLE WALLED f ) 03 LINED <br /> 0. (X) 01 CARBON STEEL 1 ) 02 STAINLESS STEEL f 1 03 FIBERGLASS l ) 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> f ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( l 30 NON-METALLIC <br /> f ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) . PAGE 1 <br />