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32-6 0 <br /> STATE ID NUMBER 00000049445001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) <br /> 01 NEW PERMIT t ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPOPATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> WILLIAM BOERSMA ( ) 01 FED ( 1 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZI.P <br /> 215 PRIMULA CT. RIPON CA 95366 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SVPERVISOR <br /> K & M FARMS MARK SWASS <br /> STPEET ACDPESS NEAREST CROSS STREET <br /> 17125 S. WAGNER RD. <br /> CITY COUNTY ZIP <br /> ESCALON SAN JOAQUIN 95320 <br /> MAILING ADDRESS CITY STATE IIP <br /> 215 PRIMULA CT. RIPON CA 95366 <br /> PHONE W/APEA CODE TYPE OF BUSINESS <br /> 209-599-2033 ( 1 01 GASOLINE STATION (X) 02 OTHER ORCHARD <br /> NUMBER OF CONTAINERS PUPAL 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 /> BOERSMA, WM. 209-599-2033 SAME - - <br /> COMPLETE THE FOLLOWING 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 (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 350 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES (X) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM 1 ) 04 DIESEL ( ) 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES f ) CCM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED f 1 03 LINED <br /> D. ( ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE 1 ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> (X) 12 UNKNOWN l ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />