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XW4 <br /> STATE ID NUMBER 00000000631001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> E:��, OSED <br /> MIT [ ) 05 RENEWED PERMIT •!IdNAL PERMIT ( ) 06 AMENDED PERMIT ) 08 MI CHANGE [NO SURCHARGE 09 DELETE FROM FILE (NO FEE1 <br /> I OWNER <br /> "N=•"c(COPPORAT-CN,ZNDTVZOUAL OR PUBLIC AGENCY) <br /> NATIONAL MEDICAL ENTERPRISES, PUBLIC AGENCY ONLY <br /> ( ) 01 FED ( ) 02 STATE i ) 03 LOCAL <br /> STREET ADDRESS <br /> 11620 WILSHIRE BLVD. CITY Lcs <br /> TATE ZIPLOS ANGELES A 90025 <br /> II FACILITY <br /> FFACIL17YHDAI�-MEECATAL DEALER/FOPEMAM/SUPERVISOR <br /> FRED MARTIN <br /> STREET ADDP_SS <br /> 1205 E. NORTH STREET NEAREST CROSS STREET <br /> COTTAGE AVENUE <br /> CITY <br /> MANTECA COUNTY <br /> SAN JOAQUIN ZIP <br /> 95336 <br /> MAILING ADDRESS <br /> P.D. BOX 191 CITY STATE ZIP <br /> MANTECA CA 95336 <br /> PHONEW'/ATEA CODE <br /> 209-823-3111 TYPE OF BUSINESS <br /> ( ] 01 GASOLINE STATION (X) 02 OTHER HOSPITAL <br /> NUMBER OF CONTAIN-CRS PUPAL AREAS ONLY : <br /> 1 TOWNSHIP <br /> PA <br /> NOE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> =MARTIN3 <br /> , FIRST) AND RNOYE W/AREA CODE NIGHTS: N ME(LAST NAME FIRST) AND P?10kE W/AREA CODE <br /> /F 209-823-3111 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: <br /> -- CONTAINER NUMBER I <br /> B. MANUFACTURER (IF APPROPRIATE): SyIELD-HARPER <br /> YEAR MFG: 1981 L. YEAR INSTALLED 2981 ( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 110 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 ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM ( } 04 DIESEL ( ) 05 WASTE OIL ( } 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 12 (X) GAUGE [ ) INCHES ( } CM ( ) UNKNOWN <br /> B. f } 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( 1 03 UNKNOWN <br /> C• ( 1 01 DOUBLE WALLED ( ) 02 SINGLE WALLED (X) 03 LINED <br /> b. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE i ) 05 CONCRETE— <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE [ } 09 COMPOSITE ( } 10 NON-METALLIC <br /> i ) 12 UNKNOWN ( ) 13 OTHER: <br /> 1SC04-070185 (10/18/85) <br /> PAGE 1 <br />