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STATE ID NUMBER 00000058626003 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (K) 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> l 1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.SDUAL OR PUlI C AGENCY) PUBLIC AGENCY ONLY <br /> ROB€R*--G-9GH@tNDIZ ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS / q A �� CITY STATE ZIP <br /> 1702--lACKSBH'�T. z /L.'R��lp. ESLALON CA 95320 <br /> II FACILITY <br /> FACILITY NAME DERVx O <br /> R/ ORlM /sfR <br /> BDB'S UNION SERV. `J <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1702 JACKSON ST. CALIF. <br /> CITY COUNTY ZIP <br /> ESCALON SAN JOAQUIN 95320 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 1702 JACKSON ST. ESCALON CA 95320 <br /> PHONE W/AREA COO! TYPE OF 6USINE SS <br /> 209-838-7320 (X1 O1 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> r _ <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 COD! <br /> SCHULZ, ROBERT 209-838-3115 SAME - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) Ol TANK f ) 04 OTHER: CONTAINER NUMBER 3 <br /> B. MANUFACTURER (IP APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 2000 GALLONS ( l 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 ? (X) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 <br /> 01 UNLEADED ( ] 02 REGULAR (X) 03 PREMIUM ( ) 04 DIESEL f ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED 1 ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL f 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> 1 ) 06 ALUMINUM t 1 07 STEEL CLAD ( ] 08 BRONZE ( ) 09 COMPOSITE 1 ) 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />