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STATE TO NUMBER 00000018097002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT i ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CC=-C;ATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> BILL DARE ( ) D1 FED f ) 02 STATE ( 03 LOCAL <br /> STPEET ADCPESS CITY STATE YIP <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 /> 23.597 N HY 99 <br /> CITY COUNTY TIP <br /> ACAMPO SAN JOAQUIN 95220 <br /> MAILING A00RESS CITY STATEF95220 <br /> 2P <br /> P.O. BOX 423 ACAMPO CA <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-369-1128 ( 1 01 GASOLINE STATION (X) 02 OTHER AIRPORT <br /> NUMBER OF CONTAINERS RURAL .AREAS ONLY TOWNSHIP RANGE SECTION <br /> ooeo :7 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> 04YS: 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 DAUSE. BILL 209-369-1128 <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 /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1982 ( 1 UNKNOWN <br /> 0 <br /> D. CCNTAINER CAPACITY: 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 t ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM f l 04 DIESEL ( ) 05 WASTE OIL (X) 06 OTHER AVIATION FUEL <br /> V CONTAINER CONSTRUCTION a <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE t ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED t ) 03 UNKNOWN <br /> C. f ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> D., t 01 CARBON STEEL ( ) D2 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> 1 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE f ) 10 NON-METALLIC <br /> JA*-'Y"eRM"Mr ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />