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I <br /> STATE ID NUMBER 00000056211002 <br /> APPLICATION FOR PERMIT TO OPE ATM'ERGROUND STORAGE TANK <br /> .0a 01 NEW PER ( 1 05 RENEWED PERMIT 07 T ii0-� ( 1 09 DELETE FROM FILE (NO FEE) <br /> ( ] 02 CONDITIONAL PERMIT ( l 06 AMENDED PERMIT ( ) MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> LIBERTY RURAL COUNTY FIRE PROTLGTf ` ( 1 01 FED ( 1 02 STATE jVQJ3 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 24124 N BRUELLA RD ACAMPO CA 95220 <br /> II FACILITY <br /> FACILITY NAME J DEALER/FOREMAN/SUPERVISOR <br /> LIBERTY R Al IAFFK FIRE .S!'f(L STAN SEIFERT - FIRE CHIEF <br /> STREET AODPESS NEAREST CROSS STREET <br /> 24124 N BRUELLA RD JAHANT <br /> CITY COUNTY ZIP <br /> ACAMPO SAN JOAQUIN 95220 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 24124 N BRUELLA RD ACAMPO CA 95220 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-368-0905 ( ) 01 GASOLINE STATION (X) 02 OTHER FIRE STATION <br /> NUMBER 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/AREA CODE <br /> SEIFERT. STAN 209-968-e4i8 3 3.3 _3 3 3/� SE IF ERT. STAN zo9-aea-e4ae 33 'i—33 3fo <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 2 <br /> S. MANUFACTURER (IF APPROPRIATE)) PERKINS WELDING WORKS YEAR MFG: 1982 C. YEAR INSTALLED 1982 1 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 1000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 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 BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL 1 ) 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> D <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE l ) INCHES ( ) CM (XI UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( 7 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE ( 103 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD ( ) 08 BRONZE ( l 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ' f ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />