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STATE IO NUMBER 00000054112001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT _05­08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COR FOPATION,ItPIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> AL A BARBARA CROWj( ( ) 01 FED [ ) 02 STATE ( 7 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> P.O. BOX 81 CLEMENTS CA 95227 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> PACIFIC CORPORATION AL CROW/ �n, (-( r <br /> STREET ADDRESS NEARE T CROSS STRE <br /> 16776 E. B ST. (_C tl/ e, <br /> CITY COUNTY ZIP <br /> CLEMENTS SAN JOAQUIN 95227 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P.O. BOX 445 CLEMENTS CA 95227 <br /> PHCNE W/ARCA CODE TYPE OF BUSINESS <br /> 209-759-3324 ( ) 01 GASOLINE STATION (X) 02 OTHER REPAIR SERVICE <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> <A I <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 /> CROW, AL 209-759-3324 SAME 209-759-3468 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. tX) 01 TAMC ( ) 04 OTHER: CONTAINER NUMBER 2 <br /> B. MANUFACTURER (IF APPROPRIATE): SCK YEAR MFG: C. YEAR INSTALLED 1973 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 350 GALLONS f ] UNKNOWN E. DOES THE CONTAINER STORE: f ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES (X) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( 1 04 DIESEL f 1 05 WASTE OIL X) 06 OTHER tW P-ru& Q' <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( 7 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. t 1 01 DOUBLE WALLED 0d' 02 SINGLE WALLED ( 1 03 LINED <br /> D. (X) 01 CARBON STEEL ( l 02 STAINLESS STEEL ( 1 03 FIBERGLASS l 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD t ) 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> �pw �� <br />