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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 ) 01 NEW PERMIT ( 105 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 1 ) 02 CONDITIONAL PERMIT (X) 06 AMENDED PERMIT ( 1 04 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.INDIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> LIBERTY RURAL COUNTY FIRE PROTECTION DISTRICT ( 1 01 FED ( ) 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS CITY STATE IIP <br /> 24124 N BRUELLA RD AMP <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMEN/SUPERVISOR <br /> LIBERTY RURAL COUNTY EIRE PROT- DIST - STAN SPIERRIZUTRE <br /> STREET AODPESS NEAREST CROSS STREET <br /> 24124 N BRUELLA RD JAHANT ROAD <br /> CITY ACAMPO DDUNTSYAN JOAQUIN ZIP 95220 <br /> MAILING ADDRESS CITY STATE ZIP <br /> SAME <br /> PHONE W/APEA CODE TYPE OF BUSINESS <br /> 209 - 368-06905 l 1 01 GASOLINE STATION (X) 02 OTHER <br /> NUMBCR OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 2 <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/APEA CODE <br /> STAN SEIFERT 209 - 333-3336 SAME <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 02 OTHER: CONTAINER NUMBER J393235 <br /> B. MANUFACTURER (IF APPROPRIATE)= TRUSCO TANK INC YEAR MFG: f871 C. YEAR INSTALLED )87 f ) UNKNOWN <br /> D. CONTAINER CAPACITY: 525 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE= f 1 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? l 1 01 YES l 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( )1 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL t 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( 1 INCHES ( 1 CM ( 1 UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. (X) 01 DOUBLE WALLED ( 1 02 SINGLE WALLED 1 ) 03 LINED <br /> D. 1 ) 01 CARBON STEEL l 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE t 1 05 CONCRETE <br /> ( 1 06 ALUMINUM l ) 07 STEEL CLAD ( ) 08 BROtIZE l 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> t 1 12 UNKNOWN (X) 13 OTHER: STEEL FIBERGLASS Cltlwr <br /> HSC04-070185 PAGE 1 <br /> SEE n 1987 <br /> `+ ENVIROMENTAL HEALTH <br /> PERMIT/SERVICES <br />