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STATE 20 NUMBER 00000004417001 <br /> APPLICATION FOR PERMIT TO OP GROUND STORAGE TANK <br /> 01 NEW PERMIT ( l 05 RENEWED PERMIT 07 T ( 7 09 DELETE FROM FILE (MO FEE) <br /> ( 02 CONDITIONAL PERMIT ( 1 Ob AMENDED PERMIT MINOR CHANG 0 SURCHARGE) <br /> I OWNER <br /> NAME(COP.PORATION,ZNDIVIDUAL OR PUBLIC AGENCY PUBLIC AGENCY ONLY <br /> JOHN A. TKACZYK INC DBA INDUST ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 429 PINE ST RIPON CA 95366 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> INDUSTRIAL LABS <br /> STREET ADDRESS NEAREST CROSS STPEET <br /> 429 PINE ST ELM <br /> CITY COUNTY ZIP <br /> RIPON SAN JOAQUIN 95366 <br /> MAILING ADDRE S r.1TY - STATE ZIP <br /> l 0 8 CA <br /> PHONE W/APE 00 2- 0 " TYPEOF BUSINESS <br /> 209 ( ) 01 GASOLINE STATION (X) 02 OTHER MFG. <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 /> TKACZYK JOHN A 209-575-4086 VAN PELT RUSSELL 209-674-1358 <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):JXMN6,�- YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS (X) 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 /> .f-:H-0;6_UNL.EADeb ( 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL f ) 05 WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE [ 1 INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 1 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> D. f 9 01 CARBON STEEL ( ) 02 STAINLESS STEEL f ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE [ ) 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( l 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> • r <br />