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• • STATE ID NUMBER 00000023026001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ] 01 NEW PERMIT f 1 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(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> SAN JOAQUIN COUNTY f ) 01 FED ( ) 02 STATE �l 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 222 E. WEBER STOCKTON CA 95202 <br /> II FACILITY <br /> FACILITY NAME S. F. 60, �/� 1I DEALER/FOREMAN/SUPERVISOR! - <br /> AGRICULTURAL COMMISSIONER'S OFF(C�,— Ma(4ecGL- MARY JENSEN, w�- Cld/Y1+' . - 5Vr,r 'V(SOt- <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 392 S. MOFFATT BLVD. SHERMAN <br /> CITY COUNTY ZIP <br /> MANTECA SAN JOAQUIN 95336 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 392 S. MOFFATT BLVD. MA14TECA CA 95336 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-823-9305 ( ) 01 GASOLINE STATION (X) 02 OTHER COUNTY AGENCY <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> Y <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME( LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) NO PHONE W/AREA CODE <br /> ERGENG 209-944-2111 .J O.r�.S �� 4S�/- -2��� <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER M-1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 1000 GALLONS ( ) UNKNOWN E. GOES THE CONTAINER STORE: f ) 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 /> (XI 01 UNLEADED ( ) 02 REGULAR ( l 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE f ) INCHES ( 1 CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED X 02 SINGLE WALLED ( 1 03 LINED <br /> 0. ( 1 01 CARBON STEEL f ) 02 STAINLESS STEEL f l 03 FIBERGLASS ( l 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> i ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ] 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />