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• • STATE ID NUMBER 00000058183001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 NEW PERMIT ( ] 05 RENEWED PERMIT t ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPOPATION,INDIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> MERROL CLARK ( 1 01 FED f ) 02 STATE f ) 03 LOCAL <br /> STREET ADOPESS CITY STATE ZIP <br /> 1745 SECOND ST. ESCALON CA 95320 <br /> II FACILITY <br /> I <br /> L <br /> FACITY NAME DEALER/FOREMAN/SUPE�IL <br /> �SO[t <br /> FACILITY <br /> MERPOL CLARK YtG> <br /> STREET ADDRESS NEAREST CROSS STREET Li <br /> 1745 SECOND ST. JACKSON ST <br /> CITY COUNTY ZIP <br /> ESCALON SAN JOAQUIN 95320 <br /> MAILINGADDRESS ^ \ Q CITY STATE ZIP <br /> O J ESCALON CA 95320 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-838-2443 ( ) 01 GASOLINE STATION (X) 02 OTHER PRIVATE <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> 1 2S 9E 4 <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 /> ,kt209-a3e-raar -S S-F-73Kd aAHe- <br /> APLE E *HE FOLLOWING ON A SEPARATE FORM FOR EACH ONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: CONTAINER NUMBER I <br /> B. MANUFACTURER (IF APPROPRIATE): MOWEL CO 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 ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES)- <br /> ( ) 01 UNLEADED ( 1 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL ( ) 05 WASTE OIL f 7 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ] GAUGE ( l INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( 1 03 LINED <br /> 0. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( l 10 NON-METALLIC <br /> ( ) 12 UNKNOWN t ) 13 OTHER: <br /> HSC04-070185 (10/18/85) <br /> PAGE 1 <br /> 0 <br />