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STATE ID NUMBER 00000059807001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT f 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> SIMON J. WESTSTEYN ( I O1 FED ( ) 02 STATE f 1 03 LOCAL <br /> STREET ADOP.ESS CITY STATE ZIP <br /> 23309 S. JACKTONE RIPON CA 95366 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> SIMON J. WESTSTEYN <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 23309 S. JACKTONE <br /> CITY COUNTY ZIP <br /> SAME SAN JOAQUIN 95366 <br /> MAILING ADDRESS CITYSTATE ZIP <br /> 23309 S. JACKTONE SAME CA 95366 <br /> PHONE W/AREA CODE TYPEOF BUSINESS <br /> 000-000-0000 ( 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 /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> WESTSTYN, SIMON J. 000-000-0000 Gig- 79 1 SAME - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1975 f ) UNKNOWN <br /> 0. CONTAINER CAPACITY: 300 )GALLONS f l UNKNOWN E. DOES THE CONTAINER STORE: f I 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 (X) 03 PREMIUM ( ) 04 DIESEL l 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE f 1 INCHES ( ) CM (X) UNKNOWN <br /> B. l ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f l 02 NDN-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( 1 03 LINED <br /> D. [ 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL f ) 03 FIBERGLASS ( l 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM f ) 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN (X) 13 OTHER: STEEL TAREWRAPPED <br /> HSC04-070185 (10/18/85) PAGE 1 <br />