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STATE ID NUMBER 00000018097COI <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> i ) 01 NEW PERMIT f ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEEL <br /> t 1 02 CONDITIONAL PERMIT € ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CCP.P r4TION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> BILL PeE 01 FED f 1 02 STATE [ 1 03 LOCAL <br /> STP.EET ADDRESS CITY - STATE ZIP <br /> P.O. BOX 423 ACAMPO CA 95220 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> BILL DAUSE <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 23597 N HY 99 <br /> CITY COUNTY ZIP <br /> ACAMPO SAN JOAQUIN 95220 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P.O. BOX 423 ACAMPO CA 95220 <br /> PHONE W:AREA CODE =TYPEOFNESS <br /> 209-369-1128 LINE STATION (X) 02 OTHER AIRPORT <br /> NUMBER OF.CONTAZNERS RURAL AREAS ONLY TOWNSHIP T-—PgNGESECTIONSCTION <br /> III 24 SCOUR 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 /> DAUSE, BILL 209-369-1128 DAU5E, BILL 209-369-1128 <br /> COMPLETE THE FOLLOWING ON A SEPARATE= FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A, (X) 01 TANK i l 04 OTHER: CONTAINER NUMBER. 1 <br /> 8, MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1982 t ) UNKNOWN <br /> D. CONTAINER CAPACITY: 5000 GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER ST-DRE: [ ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL (X) 06 OTHER AVIATION FUEL <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( 1 CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. t 1 01 DOUBLE WALLED f,'1 02 SINGLE WALLED ( 1 03 LINED <br /> D. (. 7 01 CARBON STEEL ( ) 02 STAINLESS STEEL [ 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> T ) 13 OTHER: <br /> HSC04-070185 (10/18/85) <br /> PAGE 1 <br />