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4 <br /> � STATE ID NUMBER 00000023025001 <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 /> f ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORFORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> SAN JOAQUIN COUNTY ( ) 01 FED ( ) 02 STATE (Wj 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 222 E. WEBER STOCKTON CA 95202 <br /> II FACILITY n <br /> FACILITY NAME J� J o-- {q{ v 1 DEALER/FOREMAN/SUPERVISOR <br /> AGRICULTURAL COMMISSIONER'S 0 1G� cc ori MARY JENSENJ P Al Y (om V)�' <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1540 ROOSEVELT MCHENRY <br /> CITY COUNTY <br /> ZIP <br /> ESCALON SAN. JOAQUIN 95320 <br /> MAILINO AODPESS CITY STATE ZIP <br /> 1540 ROOSEVELT ESCALON CA 95320 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-S3S-2276 ( ) O1 GASOLINE STATION (X) 02 OTHER COUNTY AGENCY <br /> NUMBER OF CONTAIN''-RS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 3 <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 /> °^9-944-2111 Cv, 095 <br /> 5 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER E-1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: I C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 1000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X1 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> (X) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE f l INCHES ( 1 CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. [ 1 01 DOUBLE WALLED (V-02 SINGLE WALLED ( ) 03 LINED <br /> D. ( 1 01 CARBON STEEL f 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />