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1 STATE ID NUMBER 00000058262002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) O1 NEW PERMIT ( 1 05 RENEWED PERMIT ( 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 1 02 COW ITIONAL PERMIT ( ) 06 AMENDED PERMIT C ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORFORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> WOODBRIDGE RURAL COUNTY FIRE P ( ) 01 FED ( ) 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 400 E. AUGUSTA STREET WOODBRIDGE CA 95258 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> WOODBRIDGE RURAL COUNTY FIRE PWX%;C 0.` bt47klG7_ LEONARD N. ORTIZ OftlFF <br /> STREET ADDPESS NEAREST CROSS STREET <br /> 400 E. AUGUSTA STREET <br /> CITY COUNTY ZIP <br /> WOODBRIDGE SAN JOAQUIN 95258 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P.O. BOX 186 WOODBRIDG€ CA 95258 <br /> PHONE W/AREA CODE TYPEOF BUSINESS <br /> 209-369-1945 ( ) 01 GASOLINE STATION (X) 02 OTHER FIRE DEPT. <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 2 <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 /> WOODBRIDGE FIRE DISTRICT 209-369-1945 SAME `°l- 9 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER R2 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1981 C. YEAR INSTALLED 1981 ( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 1000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: f 1 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 /> (X1 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( 1 04 DIESEL ( ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 10 (X) GAUGE ( 1 INCHES ( ) CM l 1 UNKNOWN <br /> B. f ) 01 VAULTED (LOCATES IN AN UNDERGROUND VAULT) (X) 02 NOF(-VAULTED ( ) 03 UNKNOWN <br /> C. l ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( 1 03 LINED <br /> D. (X) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM f ) 07 STEEL CLAD [ ) 08 BRONZE f ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> • HSC04-070185 (10/18/85) PAGE 1 <br /> ]P' low, <br />