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• • STATE ID NUMBER 00000005761003 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> f 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CCPPORATION,INDIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> M.K.T. (ARMS 1 7 <br /> 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS <br /> 18666 HELLO AVE. CITY STATE IIPRIPON 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 <br /> COUNTY IIP <br /> RIPON SAN JOAQUIN 95366 <br /> MAILING ADOP.ESS CITY STATE IIP <br /> 18666 MELLO AVE RIPON CA 95366 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-599-2167 f ) 01 GASOLINE STATION (X) 02 OTHER VEHICLE MAINT. <br /> NUMBER. OF CONTAINERS PUPAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> 3 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE 'A/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. (X) 01 TANK f ) 04 OTHER: CONTAINER NUMBER S3 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> /,soo <br /> 0. CONTAINER CAPACITY: 6000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE (X) 02 PRODUCT <br /> F. OES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOXf ES): <br /> (M 01 UNLEADED ( ) 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ] INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ] 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. f 1 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> 0. (X) 01 CARBON STEEL f ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> C ) 06 ALUMINUM ( ) 07 STEEL CLAD f 1 08 BRONZE ( 1 09 COMPOSITE f ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN f ) 13 OTHER: <br /> HSC04-070185 (10/18/85) <br /> PAGE 1 <br />