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STATE IO <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAG y u <br /> (yj O1 NEW PERMIT l 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED f 1 09 DE TE LFRq! /�IE f/Y�ffEEI <br /> 1 ) 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) OD MINOR CHANGE (NO SURCHARGE) IVIHI J IJOO <br /> -- - ---- -- ---- -- ENVIROMENTAL HEALTH <br /> I OWNER E FRMII/SERVICE <br /> NAM.E(COPPORATION.INOIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> Nicolaysen Farms ( I 01 FED 1 1 02 STATE l ) 03 LOCAL <br /> STREET ACCRESS CITY STAT! IIP <br /> 23073 Frederick Road Ripon CA 95366 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMENISUPERVISOP <br /> Nicolaysen Farms Kent Bybee <br /> STREET AOC'ESS NEAREST CROSS STREET <br /> Same as above West Ripon Road <br /> CITY COUNTY IIP <br /> San Joaquin <br /> Y MAILING ADOPESS CITY STATE ZIP <br /> t _P.o.-, Box 668 Ripon CA 95366 <br /> PHONE W'APEA CODE TYPE OF BUSINESS <br /> - 209 599-2116 l 1 01 GASOLINE STATION 1X1 02 OTHER <br /> tNUP. P OF CONTAINERS PUPAL AREAS ONLY TONNSNip RANGE <br /> SECTION <br /> T2 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> Y.E(LAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> Lam, Kent (209) 599-2il6 Bybee, Kent (209) 577-8281 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( X 01 TANK ( ) 02 OTHER: CONTAINER NUMBER N/A <br /> I <br /> B. MANUFACTURER (IF APPROPRIATE): N/A YEAR MFG: N/A C. YEAR INSTALLED 1982 1 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: 6500 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: f 1 01 WASTE l X 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (71 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> 1 I4 01 UNLEADED ( 1 02 REGULAR ( ) 03 PREMIUM l 1 04 DIESEL ( l 05 WASTE OIL t 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICY.NESS OF PRIMARY CONTAINMENT: ( 1 GAUGE f 1 INCHES ( 1 CM 1X1 UNKNOWN <br /> S. 1 1 01 VAULTED (LOCATED IN AN UNOERGROUND VAULT) l XI 02 HON-VAULTED ( 1 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( N 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM l 1 07 STEEL CLAD ( 1 OB BROfIZE 1 ) 09 COMPOSITE f 1 10 NON-METALLIC <br /> l 112 UNKNOWN t 1 13 OTHER: <br /> HSC04-070185 PAGE 1 <br />