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STATE ID NUMBER 00000059724001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> CLOSED01 NEW PERMIT 05 RENEWED PERMIT ( ) 07 TAW I 09 DELETE FROM FILE (NO FEE) <br /> (t ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> FNAME(COPPOPkTION�,INOIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> 1 O1 FEO ( 1 02 STATE ( 103 LOCAL <br /> NCRETE PIE SERVILEADDRESS CITY STAT[ LZP <br /> TADDEI RD. ACAMPO CA 95220 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/ UPERVISOR <br /> HARRY LORZ filr_ r Lzr?-, <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 381 W. TADDEI RD. BENDER <br /> COUNTY ZIP <br /> CITYPO SAN JOAQUIN 95220 <br /> ACA <br /> CITY STATE ZIP <br /> MAILING ADDRESS CA 95220 <br /> 381 W. TADDEI RD. ACAMPO <br /> PHONE W/APEA CODE TYPE OF BUSINESS <br /> 209-369-3306 ( I O1 GASOLINE STATION (X) 02 OTHER IRRIGATION <br /> NUMBER Of CONTAINERS <br /> RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> 2 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAMEILAST N ME FIRST) ,AND P ONE W/ARCA COD <br /> *LuaI.,A11 SIGH <br /> c 209-369-3306 3.30 <br /> COMPLEV THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK t ,1 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1973 ( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 500 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 ? (X) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM ( 1 04 DIESEL 1 ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 1 GAUGE ( 1 INCHES l 1 CM (X) UNKNOWN <br /> B. l 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (,A) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 ) 06 ALUMINUM ( 1 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE f 1 10 NON-METALLIC <br /> (X) 12 UNKNOWN l 113 OTHER: <br /> PAGE I <br /> HSC04-070185 (10/18/85) <br />