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STATE IOWm ER 00000033591002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORA TANK <br /> ( 1 <br /> 01 NEW PERMIT ( 1 05 RENEWED PERMIT 4107 TANK CLOSED ( 09 DELETE FROM FILE (NO FEE) <br /> f 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPOPATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> O*Lr BRRIA DEPARTMENT OF CORR. ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE 2IP <br /> P.O. BOX 714 SACRAMENTO CA 95803 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> DEUEL VOCATIONAL INSTIMION HIE OF PLANT OPERArAC}1$ <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 23500 KASSON ROAD 1-5 <br /> CITY COUNTY ZIP <br /> TRACY SAN JOAQUIN 95376 <br /> MAILING ADDRESS CITYSTATE IIP <br /> P.O. BOX 400 TRACY CA 95376 <br /> PHONE W/AREA coOE T PEOF BUSINESS Xl O1 GASOLINE STATION kl 02 OTHER n <br /> 209-835-4141 ems, C.OT'�f�ph 2'll Cl-Y(5!L Ttt•�C <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 4 <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 /> 209-835-4141 209-835-4141 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 2 <br /> S. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> yoft <br /> D. CONTAINER CAPACITY: '3940. GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: [ ) 01 WASTE f 02 PRODUCT <br /> F. ODES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (-Xf 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> l 1 <br /> 01 UNLEADED ( 1 02 REGULAR P'6 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( ! CM (X) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED L?d 02 SINGLE WALLED ( 1 03 LINED <br /> 0. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 7 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD ( 1 08 BRONZE f 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> i <br />