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• 2 6 • STATE ID NUMBER 00000030962002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 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(COPPOPATION,INOIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> HERMAN VAN RYN ( ) 01 FED ( ) 02 STATE f ) 03 LOCAL <br /> STREET ADOPESS CITY STATE ZIP <br /> 19565 S. SEXTON RD. ESCALON CA 95320 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> HERMAN VAN RYN <br /> STFEET =OO2ESS NEAREST CROSS STREET <br /> 19565 S SEXTON RD. HWY 120 <br /> CITY COUNTY ZIP <br /> ESCALON SAN JOAQUIN 95320 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 19565 S. SEXTON RD. ESCALON CA 95320 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-838-7437 ( ) 01 GASOLINE STATION (X) 02 OTHER AGRIC <br /> NUMBER OF CONTAINERS PUPAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 2 2S BE 12 <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 /> 209-838-7437 VAN RYN H. 209-838-7437 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 2 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1972 C. YEAR INSTALLED 1972 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 550 GALLONS f l UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM l ) 04 DIESEL ( l 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 12 (X) GAUGE ( 1 INCHES ( ) CM f l UNKNOWN <br /> B. ( ) 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 ( 1 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-07D185 (10/18/85) PAGE 1 <br />