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STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> I ( 1 01 NEW PERMIT ( ) 05 RENEWED PERMIT t ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ! 1 02 CONDITIONAL PERMIT lX) 06 AMENDED PERMIT f ) 04 MINOR CHANGE (NO SURCHARGE) - <br /> I OWNER <br /> NAME(COPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> LIBERTY RURAL COUNTY FIRE PROTECTIQN DISTRICT ( ) 01 FED t ) 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS CITY STATE SIP <br /> 24124 N BRUELLA RD ACAMPO CA <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMEN/SUPERVISOR <br /> LIBERTY RURAL COUNTY FIRE PROT. DIST. STAN SETFERT/CTITFF <br /> STREET ADOPESS NEAREST CROSS STREET <br /> 24124 N BRUELLA RD ACAMPO JAHANT RD <br /> CITY COUNTY ZIP <br /> SAN JOA UIN <br /> MAILING ADDRESSCITY STATE ZIP <br /> SAME <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 20 - t ) 01 GASOLINE STATION (X) 02 OTHER <br /> NUP..BER OF CONTAINERS PUPAL 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: NAMCf LAST NAME FIRST) AND PHONE W/AREA CODE <br /> STAN SEIFERT - 209 333-3336 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 02 OTHER: ICONTAINER NUMBER J393235 <br /> B. MANUFACTURER (IF APPROPRIATE): TRUSCO TANK INC YEAR ' R7 I C. YEAR INSTALLED ) 87 l ) UNKNOWOt <br /> D. CONTAINER CAPACITY: 525 GALLONS t ) UNKNOWN I E. DOES THE CONTAINER STORE: ( ) 01 WASTE ( 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOKt ES): <br /> l ) 01 UNLEADED l ) 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL ( ) 05 WASTE OIL [ ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. TH ICY.NESS OF PP.IMARY CONTAINMENT: ( 1 GAUGE f 1 INCHES ( ) CM 1 ) UNKNOWN <br /> B. 1 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) OC ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. KXi 01 DOUBLE WALLED t 1 02 SINGLE WALLED l 1 03 LINED .. <br /> D. f ) 01 CARBON STEEL l 1 02 STAINLESS STEEL [ ) 03 FIBERGLASS l 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> 1 1 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE 1 ! 09 COMPOSITE ( 110 NON-METALLIC <br /> 1 ) 12 UNKNOWN KA 13 OTHER: STEEL- FIBERGLtSS <br /> HSC04-070185 PAGE 1 <br />