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• • STATE ID NUMBER 00000023025003 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT 0<r07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( l 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> SAN JOAQUIN COUNTY ( ) 01 FED l ) 02 STATE (,)0-03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 222 E. WEBER STOCKTON CA 95202 <br /> II FACILITY`s / <br /> FACILITY NAME �V , DEALER/FOREMAN/SUPERVISOR <br /> AGRICULTURAL COMMISSIONER'S OPPr(-I:-: — Escc4L MARY JENSEN.) Da+?.t - Comm • - 5 e�visd( <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1540 ROOSEVELT MCHENRY <br /> CITY COUNTY IF <br /> ESCALON SAN JOAQUIN 95320 <br /> MAILING ADDPESS CITY STATE ZIP <br /> 1540 ROOSEVELT ESCALON CA 95320 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-838-2276 ( ) 01 GASOLINE STATION (X) 02 OTHER COUNTY AGENCY <br /> NUMBER OF CONTAINERS 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: NAMEt LAST NAME FIRST) AND PHONE W/AREA CODE <br /> 209-944-2111 s.J. (p. 0E5 a09-` !` -2 J// <br /> . <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER E-3 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> 0. CONTAINER CAPACITY: 1000 GALLONS t ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES (X) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> t ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM f l 04 DIESEL l ) 05 WASTE OIL ( l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE f ) INCHES f ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED oG 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( 1 01 CARBON STEEL t ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE l 1 09 COMPOSITE ( ] 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />