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STATE ID NUMBER 00000038165004 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f 1 01 NEW PERMIT f ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT f ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NATE-(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> JDP)c P"MS, SHAD L. DIETS I( ) 01 FED ( ) 02 STATE f ] 003 �LOCAL <br /> STREET ADDRESS CITY <br /> 608 SFMONS ST ' <br /> II FACILITY <br /> FACILITY NAME - DEALER/FOREMAN/SUPERVISOR <br /> CLEMENTS AUTOMOTIVE REPAIR C#AkIFJ ZA A,) <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 18633 HWY. 88 NEXT TO BRIE STATION <br /> CITY COUNTY ZIP <br /> CLEMENTS SAN JOAQUIN 95632 <br /> MAILING ADDRESS CITYSTATE ZIP <br /> BOX 314 CLEMENTS CA 95632 <br /> PHONE :,AREA CODE TYPE OF BUSINESS <br /> 209-759-"ft ` S u f (XI 01 GASOLINE STATION f ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 4 <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/AREA CODE <br /> J)LZVU-RKGADMC,i_4,w,6 09-274-4402 SAME - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 4 <br /> B. MANUFACTURER (IF APPROPRIATE): ?????????????????????????????? YEAR MFG: ???? C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 500 GALLONS f 1 UNKNOWN E. DOES THE CONTAINER STORE: f 1 01 WASTE lX) 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 /> (X) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL f ) 05 WASTE OIL ( 7 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE l ) INCHES ( ) CM (X) UNKNOWN <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. (X) 01 DOUBLE WALLED f 1 02 SINGLE WALLED f ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM (X) 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE t ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />