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• EU0 STATE I0 NUMBER 00000014672001 <br /> A <br /> APPLICATION FOR PERMIT TO OPE R TDERGROUND STORAGE TANK <br /> ( ) 01 NEW PERMIT ( l 05 RENEWED PERMIT ( 07 TANK CLDSFII ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT 1 U8 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> RUSSELL POTTER ( ) 01 FED f ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 19268 S ST JOHN ESCALON CA 95320 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> RUSSELL POTTER SELF <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 19268 S ST JOHN CATHERINE WAY <br /> CITY . COUNTY ZIP <br /> ESCALON SAN JOAQUIN 95320 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 19268 S. ST JOHN ESCALON CA 95320 <br /> PHONE W/APEACODE TYPE OF BUSINESS <br /> 209-838-2919 ( ) 01 GASOLINE STATION (X) 02 OTHER <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/APEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> POTTER RUSS 209-838-2919 . SAME - - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 365 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 /> ( ) 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM f ) 04 DIESEL f ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 12 (X) GAUGE ( ) INCHES ( ) CM ( ) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (XI 02 SINGLE WALLED ( 1 03 LINED <br /> D. (X) 01 CARBON STEEL ( 102 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ] 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD ( ) 08 BRONZE ( l 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> 0 0 <br />