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`/\►v \00Iftmool STATE ID NUMBER 00000035819001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f ) <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( l 06 AMENDED PERMIT [ 108 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CHARLES RICHARD DAWSON ( ) 01 FED ( ) 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS CITY STATE 2IP <br /> 20904 MCHENRY ESCALON CA 95320 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> DAWSON RANCH LOC A3 <br /> STPEET ADDRESS NEAREST CROSS STREET <br /> 21635 MCHENRY RIVER RD. <br /> CITY COUNTY IIP <br /> ESCALON SAN ON 95320 <br /> JOAQUIN 95320 <br /> CITY STATE ZIP <br /> MAILING ADDRESS ESCAL <br /> 20904 MCHENRY <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-838-7502 ( ) 01 GASOLINE STATION (X) 02 OTHER FARMING <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> 1 2S 9E 17 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(IAST NAME FIRST) AND PHONE W/AREA CODE RIGHTS: NAME(LAST NAME FIRST) AND PRONE W/AREA eooE <br /> CHARLES R. DAWSON 209-838-7502 SAME - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 004 <br /> B. MANUFACTURER (IF APPROPRIATE): MODESTO TANK YEAR MFG: 1969 C. YEAR INSTALLED 1969 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 300 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ! 7 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES ( ) 02 NO IF YES CHECK.APPROPRIATE BOX(ES): <br /> ( 1 <br /> 01 UNLEADED ( 1 02 REGULAR ( ) 03 PREMIUM ( l 04 DIESEL ( 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 12 (X) GAUGE ( 1 INCHES ( ) CM ( 7 UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON—VAULTED ( ) 03 UNKNOWN <br /> C. ! 1 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( 1 03 LINED <br /> 0. (X) 01 CARBON STEEL f ] 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE [ ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ! ) 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON—METALLIC <br /> ( ) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> low \/ <br />