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1 • • STATE ID NUMBER 00000005761002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 NEW PERMIT ( ) 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(COPPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> M.K.T. FARMS f ) 01 FED ( 1 02 STATE f ) 03 LOCAL <br /> STREET ADDRESS CIT) STATE ZZP <br /> 18666 MELLO AVE. RIPON CA 95366 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> SHOP ERIC JACOBSEN <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 19201 MELLO AVE. CARROLTON <br /> CITY COUNTY ZIP <br /> RIPON SAN JOAQUIN 95366 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 18666 MELLO AVE RIPON CA 95366 <br /> PHONE W/APE4 CODE TYPE OF BUSINESS <br /> 209-599-2167 ( ) 01 GASOLINE STATION (X) 02 OTHER VEHICLE MAINT. <br /> NUMBER OF CONTAINS P.S RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 3 <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 /> JACOBSEN.ERIC 209-599-2312 JACOBSEN,ERIC 209-599-2692 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (XI 01 TANK ( ) 04 OTHER: CONTAINER NUMBER S2 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) 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 ( ] 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE t l INCHES ( I CM (X) UNKNOWN <br /> B. ( 101 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 102 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( 103 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL f 1 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM [ ) 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> f ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />