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STATE ID NUMBER 00000045445001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 <br /> 01 NEW PERMIT ( 1 OS RENEWED PERMIT ( ) 07 TANK CLOSED <br /> ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT f 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (ND SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> f l 01 FED f 1 02 STATE [ 1 03 LOCAL <br /> HENRY J. GROEN <br /> STREET ADDRESS CITY STATE ZIP <br /> 23333 BROWN MANTECA CA 95336 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> HENRY J. GROEN <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 23333 BROWN <br /> CITY COUNTY ZIP <br /> MANTECA SAN JOAQUIN 95336 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 23333 BROWN MANTECA CA 95336 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-599-4987 ( 1 01 GASOLINE STATION (X) 02 OTHER <br /> NUMBER Of CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 1 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> OATS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> GROEN. HENRY J 209-599-4987 SAME - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (XI 01 TANK f 1 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1960 C. YEAR INSTALLED 1960 f 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 300 GALLONS f 1 UNKNOWN E. DOES TME CONTAINER STORE: ( 1 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 80X(ES): <br /> f ) 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM f 1 04 DIESEL f 1 05 WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE l ) INCHES ( 1 CM (X) UNKNOWN <br /> S. l 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f 1 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED f 1 02 SINGLE WALLED ( ) 03 LINED <br /> D. (X) 01 CARBON STEEL f 1 02 STAINLESS STEEL f ) 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( l 08 BRONZE f 1 09 COMPOSITE l 1 10 NON-METALLIC <br /> f 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> ,mo/ <br />