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• <br />STATE ID NUMBER 00000011196003 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />!'1M .—t 0""' - 1 ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEEI <br />l ) 02 CONDITIONAL PERMIT 1 ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NaME(COPPOPAT:ON.INO A'ID'JAL OR PU6LIC AGENCY) - PUBLIC AGENCY ONLY <br />E -Z SERVE, INC. I ) 01 FED I ) 02 STATE f ) 03 LOCAL <br />STREET=COC!SS CITY STATE ZIP <br />901 SOUTH 1ST. ABILENE TX 79602 <br />II FACILITY <br />FACILITY NAME <br />24 HOUR EMERGENCY <br />OEALEP/FOREMAN/SUPERVISOR <br />CONTAINER NUMBER 63 <br />MADSEN'S SUNRISE DAIRY <br />NAM!(LAST NAME FIRST) AND <br />PHONE W/AP.EA CODE <br />STP'_ET 4^-CFESS <br />19t*i+ERrRA•1`_ <br />NEAPES CROSS STREET <br />08 75-� _ <br />239 SOUTH STOCKTON <br />WEAU� 61Y-?6t-ii3Y <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO <br />( ) 01 UNLEADED (X) 02 REGULAR t ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL l <br />IF YES CHECK APPROPRIATE BOX(ES): <br />) 06 OTHER <br />CITY <br />POLYVINYL CHLORIDE t l 05 CONCRETE <br />( 1 10 NON-METALLIC <br />COUNTY <br />ZIP <br />RIPON <br />SAN JOAQUIN <br />95366 <br />MAILING ACCO!SS <br />P.O. BOX <br />CITY <br />STATE <br />ZIP q'�� <br />/ I <br />PHONE W:AP!ACJy E <br />T'P! OF EUS/NESS <br />X) 01 GASOLINE STATION ( ) 02 OTHER <br />NUM9EP OF CONTAINERS <br />PUPAL <br />AREAS ONLY <br />TOWNSHIP <br />RANO! <br />SECTION <br />3 <br />III <br />24 HOUR EMERGENCY <br />CONTACT PERSON <br />CONTAINER NUMBER 63 <br />DAYS: <br />NAM!(LAST NAME FIRST) AND <br />PHONE W/AP.EA CODE <br />C. <br />NIGHTS: NAMEILAST NAME FIRST) AND PHONE W/APEA CODE <br />19t*i+ERrRA•1`_ <br />-619 44h <br />08 75-� _ <br />) 01 WASTE (X) 02 PRODUCT <br />WEAU� 61Y-?6t-ii3Y <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( ) 04 OTHER: <br />CONTAINMENT: ( ) GAUGE ( ) INCHES f <br />CONTAINER NUMBER 63 <br />B. <br />MANUFACTURER (IF APPROPRIATE): BAGWELL <br />YEAR MFG: <br />C. <br />YEAR INSTALLED 78 l ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: 6016 GALLONS ( I UNKNOWN <br />E. DOES THE CONTAINER STORE: f <br />) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO <br />( ) 01 UNLEADED (X) 02 REGULAR t ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL l <br />IF YES CHECK APPROPRIATE BOX(ES): <br />) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY <br />CONTAINMENT: ( ) GAUGE ( ) INCHES f <br />l CM (X) UNKNOWN <br />B. <br />( ) 01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (XI 02 MON-VAULTED 1 <br />103 UNKNOWN <br />C. <br />t ) 01 <br />DOUBLE WALLED <br />(X) 02 SINGLE WALLED t ! 03 LINED <br />D. <br />(X) 01 <br />1 ) <br />f 1 12 <br />CARBON STEEL <br />06 ALUMINUM <br />UNKNOWN l ! <br />f ! 02 STAINLESS STEEL t 1 03 FIBERGLASS 1 1 04 <br />( 1 07 STEEL CLAD 1 ) 08 BRONZE ( 1 09 COMPOSITE <br />13 OTHER: <br />POLYVINYL CHLORIDE t l 05 CONCRETE <br />( 1 10 NON-METALLIC <br />HSC04-070185 (10/18/85) <br />0 N . � <br />PAGE 1 <br />