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• • STATE ID NUMBER 00000054114001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) O1 NEW PERMIT ( ) 05 RENEWED PERMIT TANK ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT t ) 06 AMENDED PERMIT R CHANGE IND SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INOIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> AL & BARBARA CROW Y ) 01 FED 1 1 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> MAIL - P.O. BX 81 CLEMENTS CA 95227 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> CENTRAL VALLEY BUILDER SUPPLY LES BROOKS <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 22500 3RD ST. HWY 88 <br /> CITY COUNTY ZIP <br /> CLEMENTS SAN JOAQUIN 95227 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P.O. BOX 61 CLEMENTS CA 95227 <br /> PHONE W/AP.EA CODE TYPE OF BUSINESS <br /> 209-759-3328 ( ) 01 GASOLINE STATION (X) 02 OTHER LUMBERYARD <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 /> BROOKS, LES 209-759-3328 BROOKS, LES 209-763-5519 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK 1 1 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 1000 GALLONS ( l UNKNOWN E. DOES THE CONTAINER STORE: ( 1 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 /> t ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL ( l 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE t ) INCHES f 1 CM (X) UNKNOWN <br /> B. [ 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. t 1 01 DOUBLE WALLED ( l 02 SINGLE WALLED ( ] 03 LINED <br /> 0. ( 1 01 CARBON STEEL f 1 02 STAINLESS STEEL 1 ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ] 05 CONCRETE <br /> ( ) 06 ALUMINUM f ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />