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STATE ID NUMBER 00000003367008 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED 09 DELETE FROM FILE (NO FEE) <br /> ( l 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAI OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> J.R. SIMPLOT COMPANY ( ) 01 FED f 1 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 999 MAIN ST. (ONE CAPITAL CENT BOISE ID 83707 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> J.R. SI11PLOT COMPANY (LATHROP <br /> STREET ADDRESS _ NEAREST CROSS STREET <br /> 16777 S. HOWLAND ROAD LOUISE AVENUE <br /> CITY COUNTY ZIP <br /> LATHROP SAN JOAQUIN 95330 <br /> MAILING ADDRESS CITY STATE IIP <br /> P. 0. BOX 198 LATHROP CA 95330 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-858-2511 ( ) 01 GASOLINE STATION (X) 02 OTHER AS CHEM AND FER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 37 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODENIGHTS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE <br /> EDSON, ROBERT W. 209-858-2511 EDSON, ROBERT W. 209-477-9780 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( ) 01 TAMC (X) 04 OTHER: SUMP CONTAINER NUMBER 114 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: I C. YEAR INSTALLED 1979 f l UNKNOWN <br /> D. CONTAINER CAPACITY: 2050 GALLONS ( 7 11NKNOWN E. DOES THE CONTAINER STORE: 1 ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES (X) 02 NO IF YES CHECK APPROPRIATE SOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 8 ( ) GAUGE (X) INCHES ( ) CM f ) UNKNOWN <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED. ( ) 03 UNKNOWN <br /> C. ( l 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( 1 03 LINED <br /> D. f 1 01 CARBON STEEL t ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE (X1 05 CONCRETE <br /> l ) 06 ALUMINUM f l 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( l 12 UNKNOWN ( ) 13 OTHER: <br /> MSC04-070185 (10/18/65) PAGE 1 <br /> NG F <br /> IIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? t ) 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 01 YES ( ) 02 NO <br /> MSC04-070185 (10/18/85) PAGE 2 <br />