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STATE IDc�°��0 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAG �7NAKV <br /> I X 01 NEW PERMIT l 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 1 09 DELETEIYkS11 41�E'Tfis FEET <br /> 1 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE IND SURCMARGEI <br /> -- - --- - -- -- --- -- — -- — ENVIROMENTA7 FIEALT" <br /> I OWNER FERMIT/SERMES <br /> HAM,E(COPPORATION,INCIVIDUAL OR FUSLIC AGENCY) PUBLIC AGENCY ONLY <br /> N1Colaysen Farms ( 1 01 FED ( 1 02 STATE ( 1 03 Local <br /> STREET ACORESS CITY STATE 215 <br /> 23073 Frederick Road Ripon CA 95366 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOPEMEN/SUPERVISOR <br /> Nicolaysen Farms Kent Bybee <br /> STREET ACD'ESS NEAREST CROSS STREET <br /> Salm as above West Ripon Road <br /> CITY COUNTY ZIP <br /> San Joaquin 95366 <br /> MAILING ADDRESSCITY STATE ZIP <br /> P.O. Box 668 Ripon CA 95366 <br /> PHONE W•AREA CODE ITYPE CF BUSINESS <br /> _ (209) 599-2116 l 1 01 GASOLINE STATION 1 M 02 OTHER <br /> NVKp EA CF CONTAINERS RVP AI APE AS ONIY (: TOWNSN2P RANGE SECTION <br /> 2 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> By:DAYSNAH,E(LAST NAME FIRST) AND PHONE W/ARU CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> bee, Kent (209) 599-2116 Bybee, Kent (209) 577-8281 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 02 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE(: N/A YEAR MFG:N/A STALLED 1979 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 10,000 GALLONS ( 1 UMNOWN E. GOES THE CONTAINER STORE: 1 1 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? IX 1 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> ( 1 01 UNLEADED (X) 02 REGULAR ( 1 03 PREMIUM l ) 04 DIESEL ( ) 05 WASTE OIL 1 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICY,MESS OF PP.IMARY CONTAINMENT: 1 ) GAUGE f ) INCHES l 1 CM l XI UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT (X 1 02 NON-VAULTED ( 1 03 UNKNOWN <br /> C. l 1 01 DOUBLE WALLED (X) 02 SINGLE WALLED l 1 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 ) 06 ALUMINUM ( 1 07 STEEL CLAD l 1 08 BR01(ZE 1 1 09 COMPOSITE 1 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( 113 OTHER: <br /> MSC04-070185 PAGE 1 <br />