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Nie u 1p <br /> # ' STATE ID NUMBER 00000029713004 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (,&,OI NEW PERMIT ( ) 05 RENEWED PERMIT (-4 07 TANK CLOSED ( 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARG ) <br /> I OWNER <br /> NAME(COPPORATION,INDZV DUAL OR PUBL C ADEN 1 PUBLIC AGENCY ONLY <br /> R ' '' te• ( CJ, ( ) O1 FEO ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE 12P <br /> 19901 SO. MCHENRY AVENUE ESCALON CA 95320 <br /> II FACILITY <br /> FACILITY NAME DEALER/FU PEPVZ OR <br /> ( rcvy� Co-, OREMAN/S <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 19901 SO. MCHENRY AVENUE CLOUGH AVENUE <br /> CITY COUNTY ZIP <br /> ESCALON SAN JOAQUIN 95320 <br /> MAILING ADDRESS - CITY STATE ZIP <br /> P.O. BOX 67 ESCALON CA 95320 <br /> PHONE W/APEA CODE TYPE OF BUSINESS <br /> 209-838-3564 ( ) 01 GASOLINE STATION (X) 02 OTHER FRESH FRUIT PROCESSI <br /> NUMBER OF CONTAI h'ERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 4 <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 /> 209-838-3809 MAR`=tH-t*FAR6k 209-83tra3BBY 7fc7 '�j <br /> K900 <br /> COMPLETE THE FOLLOWING ON A SEPARA FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 4 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1978 C. YEAR INSTALLED 1978 [ ) UNKNOWN <br /> 0. CONTAINER CAPACITY: 6000 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 /> fX) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( 7 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( l 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM (X) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />