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J <br /> STATE ID NUMBER 00000000724005 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> l� 01 NEW PERMIT f l 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT f ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> MOORE PETROLEUM I( ) 01 FED f ) 02 STATE [ ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 6TH 3 F ST BANTA CA 95304 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> MOORE PETROLEUM <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 6TH A F ST <br /> CITY COUNTY ZIP <br /> BANTA SAN JOAQUIN 95304 <br /> MAILING ADDRESS CITYSTATE ZIP <br /> P.O. BOX 67 BANTA CA 95304 <br /> PHONE W./AREA CODE TYPE OF BUSINESS <br /> 209-835-2750 (X) 01 GASOLINE STATION [ 7 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 9 <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 /> MOORE, JERRY 209-948-0749 ISI <br /> AME SAM-E - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 5 <br /> B. MANUFACTURER (IF APPROPRIATE): PERKINS YEAR MFG: 1974 C. YEAR INSTALLED 1974 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 10000 GALLONS t ) UNKNOWN E. DOES 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 /> f ) 01 UNLEADED IX) 02 REGULAR ( 1 03 PREMIUM ( ) 04 DIESEL f ) 05 WASTE OIL ( l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1/4" ( ) GAUGE (X) INCHES ( ) CM ( 1 UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED f 1 03 LINED <br /> D. (X) 01 CARBON STEEL f 1 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD ( ] 08 BRONZE f 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 7 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> `i 1./ <br />