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STATE ID NUMBER 00000037173001 <br /> APPLICATION FOR PERMIT TOATE UN U D STORAGE TANK <br /> O1 NE_ YJ-,P. RM ( ) 05 RENEWED PERMIT 7 TAN CL D .IrT 09 DELETE FROM FILE (NO FEE) <br /> 9 <br /> 1 02 L PERMIT ( ) 06 AMENDED PERMIT ( 8 MSI R ANG <br /> E RCHARGE) <br /> I OWNER I� <br /> NAME(CORPORATION.INDIVIOUAL OR PVBLIC AGENCY) PUBLIC AGENCY ONLY <br /> MOKELUMNE RURAL COUNTY FIRE PR (' ) 01 FED ( 1 02 STATE ( l 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 8910 E. HIGHWAY #12 LODI CA 95240 � <br /> II FACILITY p <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> MOKELUMNE FIRE DISTRICT LARRY D. MILLER, CHIEF <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 8910 E. HIGHWAY #12 BRUELLA ROAD <br /> CITY COUNTY <br /> ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P.O. BOX 2$T '�� VICTOR CA 95253 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-369-2913 ( ) 01 GASOLINE STATION (X) 02 OTHER FIRE DEPT <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 1 <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 /> LARRY D. MILLER 209-fts-_3B4Y LARRY D. MILLER 209-368-5091 <br /> 3b 61 <br /> COMPLETE THE FSC" G ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): - YEAR MFG: C. YEAR INSTALLED 1961 ( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: 550 GALLONS ( I 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 f ) 02 ND IF YES CHECK APPROPRIATE BOX(ES1: <br /> ( ) <br /> 01 UNLEADED ( ] 02 REGULAR (X) 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE h 1 INCHES ( ) CM (X) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( 7 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( l 07 STEEL CLAD ( ] 08 BRONZE f 1 09 COMPOSITE f ) 10 NON-METALLIC <br /> f ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />