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1 <br /> • p �� STATE IO NUMBER 00000010276001 <br /> APPLICATION FOR PERMIT TO OPERA DERGROUND STORAGE TANK <br /> ( 1 <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) NK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> f l 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MI E (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> PHS WEST, INC. ( ) 01 FED ( ) 02 STATE ( ] 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 13584 ROAD 26 MADERA CA 93639 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> PMS WEST, INC. GALE MATTHEWS <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 2130 WEST WASHINGTON PORT OF S <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95206 <br /> MAILING r.00P,ESS CITY STATE ZIP <br /> P. 0. BOX 6008 STOCKTON CA 95206 <br /> PHONE W/APEA CODE TYPE OF BUSINESS <br /> 209-466-4391 ( 1 01 GASOLINE STATION (X) 02 OTHER MANUFACTURE LIQUID F <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 2 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: N=ME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> DALE MATTHEWS 209-477-1565 DALE MATTHEWS 209-477-1565 <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 1965 ( l UNKNOWN <br /> D. CONTAINER CAPACITY: 10000 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 ( ) 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL f ) 05 WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> 0 <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE f 1 INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD ( 7 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ' ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />