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STATE ID <br /> UMBER <br /> v APPLICATION FOR PERMIT TO OPERAT UNDERGROUND STORAGENTANK 0000003e515001 <br /> (x1 <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT <br /> f 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT f 07 T�8�^ ( ) 09 DELETE FROM FILE (NO FEEL <br /> INOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORP INDIVIDUAL OR PUBLIC AGENCY) <br /> J' NC. <br /> :7/4PUBLIC AGENCY ONLY <br /> STREDRESS <br /> 01 FED ( ) 02 STATE ( ] 03 LOCAL <br /> MAIN STREET CITY STATE IIP <br /> MANT A CA <br /> 95336 <br /> FACILITY <br /> FACILIT E_ <br /> J R, INC. DEALER/FOREMAN/SUPERVISOR <br /> STREET ADOPESS �/l <br /> 123 S. MAIN STREET NEAREST CROSS STREET <br /> YOSEMITE <br /> CITY <br /> MANTECA . COUNTY <br /> SAN JOAQUIN IIP <br /> MAILING ADDR- 95336 <br /> DITY� STATE <br /> MANT ZIP <br /> PHONE W/A^ COE CA 95336 <br /> 209- 5 p TYPE OF BUSINESS <br /> / - Z �)� ( ) 01 GASOLINE STATION (X) 02 OTHER_+-_���� <br /> NUMBER OF CONTAINERS RURAL ARIAS ONIY TOWNSH2P <br /> 2 RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST)opop"mAND PHONE W/AREA CODE <br /> 209- NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> (s Ve <br /> L;UmPrrT <br /> E THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: <br /> CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): <br /> YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS (X) UNKNOWN E. DOES THE CONTAINER STORE: (X) 01 WASTE f ) 02 PRODUCT <br /> F. ( ES01HUNLEADEDNER ) 02EMOTOR REGULARVE( ) 003PREMIUM04 <br /> FUEL OR WASTE LDIESEL (XI 05 WASTE OIL ( 1 06 OTHER <br /> (X) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE ( l INCHES ( ) CM (X) UNKNOWN <br /> B• ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> ------------- <br /> C. { 7 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( 1 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( )OTHER: <br /> STEEL CLAD ( ) 08 BRONZE <br /> (X) 12 UNKNOWN 13 OTHER: <br /> ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) <br /> HSC04-070185 (10/18/85) <br /> PAGE 1 <br />