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STATE ID NUMBER 00000044127002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 O1 NEW PERMIT ( ) 09 DELETE FROM FILE (NO FEE) <br /> l 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> PUBLIC AGENCY ONLY <br /> E19688 <br /> ORPCRATION,INDIVIDUAL OR PUBLIC AGENCY) [ J 01 FED ( 102 STATE ( ) 03 LOCAL <br /> ETTINZOLI <br /> CITY STATE ZIP <br /> ADDRESS ESCALON CA 95320 <br /> S. SANTA FE <br /> OFAILITY <br /> DEALER/FOREMAN/SUPERVISOR <br /> AMENZOLINEAREST CROSS STREETDRESSSANTA FE <br /> ZIP <br /> COUNTY 95320 <br /> SAN JOAQUIN <br /> STATE ZxPcarr CADDRESS ESCALON <br /> 19688 S. SANTA FE <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 000-000-0 ( 1 01 GASOLINE STATION (X) 02 OTHER FARM <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP <br /> RANGE SECTION <br /> 2 <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 /> SETTINZOLI. JOHN 000-000-0 SAME - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION —_ <br /> A. (X) 01 TANK f ) 04 OTHER: CONTAINER NUMBER 1 <br /> S. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 350 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 /> (X) 01 UNLEADED f ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL [ ) 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE f ) INCHES ( 1 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 f 1 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL f ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> ( ) 06 ALUMINUM (X) 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> KSC04-070185 (10/18/85) PAGE 1 <br /> STATE ZD NUMBER 00000044127002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING f ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ] 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: [ ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIEST ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING: 1 ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ESI ( ) 04 PRESSURE [ 1 05 SUCTION [ 106 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> ( l 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f ) 05 SENSOR INSTRUMENT <br /> f l 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF Y00 CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ) O1 f i 02 ( ) 03 <br /> ( ) 01 ! 1 02 ( 1 03 <br /> ( ) 01 ( ] 02 f ) 03 <br /> ( ) <br /> 01 ( l 02 ( 1 03 <br /> f ) <br /> 01 ( ) 02 ( ) 03 <br /> ( 101 ( ) 02 ( ) 03 <br /> f 1 Ol ( ) 02 ( ) 03 <br /> ( ) O1 ( ) 02 1 ) 03 <br />