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STATE ID NUMBER 00000040683002 <br /> APPLICATION FOR PERMIT TO OPERATE UN GROUND STORAGE TANK <br /> ( ) Cl NEW PERMIT ( 7 05 RENEWED PERMIT f-)& Q7 TANK rngp ( ) 09 DELETE FROM FILE (NO FEE) <br /> f ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVZDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> JOHN M. BETTENCOURT --F <br /> ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDPESS CITY STATE ZIP <br /> 808 NO. L. STREET LIVERMORE CA 94550 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> COAST COUNTIES EXPRESS D.E. WINTER _44=4xf <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 4131 INDUSTRIAL WAY LARCH ROAD <br /> CITY COUNTY ZIP <br /> TRACY SAN JOAQUIN 95376 <br /> MARINO ADDRESS CITY STATE 2IP <br /> P.O. BOX 1091 TRACY CA 95376 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-835-0629 ( ) 01 GASOLINE STATION (X) 02 OTHER TRUCK TERMINAL <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY :J <br /> TOWNSHIP RANGE SECTION <br /> 2 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAME)LAST NAME FIRST) AND PHONE W/AREA CODE NIOXTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> WINTER, D.E. 209-835-0629 BURTON, GERALD 209-463-4916 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: CONTAINER NUMBER 01 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1971 f 1 UNKNOWN <br /> 0. CONTAINER CAPACITY: 1000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: f ) 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 f 1 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE f 1 INCHES f ) CM (X) UNKNOWN <br /> S. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( ) 01 CARBON STEEL f ) 02 STAINLESS STEEL l ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE f 1 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> �' S"4 <br />