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STATE SD NUMBER 00000057920003 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f 1 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TAW CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT l 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> DEPARTMENT OF CORRECTIONS ( 1 01 FED ( ) 02 STATE ( l 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 630 K STREET SACRAMENTO CA 95814 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> DEUEL VOCATIONAL INSTITUTION D.A. NEVIS C.P.O. III <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 23500 KASSON RD. I-5 <br /> CITY COUNTY IIP <br /> TRACY SAN JOAQUIN 95376 <br /> CIT <br /> .. Y STATE IIP_AILING ADDRESS TRACY CA 95376 <br /> P.O. BOX 400 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-835-4141 ( ) 01 GASOLINE STATION (X) 02 OTHER STATE PRISON <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 /> NEVIS, DAN 209-835-4141 NEVIS, DAN 209-835-4479 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 49763 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1953 ( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 12440 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 ? ( ) 01 YES (X) 02 NO IF YES CHECK APPROPRIATE BOX(ES); <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL ( ) Ob OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 5/16 ( ) GAUGE (X) INCHES ( ) CM ( 1 UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED l 1 03 LINED <br /> D. fX) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( l 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD f ) 08 BRONZE ( ) 09 COMPOSITE f ) 10 NON-METALLIC <br /> f ) 12 UNKNOWN ( 1 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 (10/18/851 <br />