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�( STATE ID NUMBER 00000055135001 <br /> I <br /> APPLICATION FOR PERMIT TO OPE ATE UNDERGROUND STORA TANK <br /> ( ) <br /> �01NEWPERMIT ( ) 05 RENEWED PERMIT (' 07 TANK CLOSED9 DELETE FROM FILE (NO FEEL <br /> t l CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COP.PORATICN,INOIVIDUAL OR PUBLIC AGENCY) Fp(u <br /> BLIC AGENCY ONLY <br /> E.L. SHAW ) 01 FED [ l 02 STATE ( l 03 LOCAL <br /> ______] <br /> ___f <br /> STREET ADDRESS CITY STATE ZIP <br /> 1407 ROOSEVELT AVE ESCALON CA 95320 <br /> II FACILITY <br /> FACILITY NAME DEALERiFOREM.AN/SUPERVISOR <br /> E.L. SHAW <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1407 ROOSEVELT AVE MCHENRY <br /> CITY <br /> COUNTY Tp <br /> I <br /> ESCALON SAN JOAQUIN 95320 <br /> MOILING ADDRESS <br /> FESCALON <br /> STATE ZIP <br /> 1407 ROOSEVELT AVE CA 95320 <br /> PHONE Wi"AP.EA CODE TYPE OF BUSINESS <br /> 209-838-7395 ( ) 01 GASOLINE STATION (X) 02 OTHER RESIDENCE <br /> NUMBER OF CONTAINERS PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 1 2S 9E 14 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME LAST NAME FIRST) .AND PHONE W/AP.E.A CODE NIGHTS: NAME( LAST NAME FIRST) AND PHONE W/AREA CODE <br /> SHAW EL 209-838-7395 SAME - - <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): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 550 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 /> ( 1 <br /> 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM f ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> lr CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 12 (X) GAUGE ( ) INCHES ( 1 CM ( ) UNKNOWN <br /> B. ( l 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( l 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE t ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />