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• 1 STATE ID NUMBER 00000GAiae8QA2-- <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f 1 O1 NEW PERMIT f 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NLME(CC2PCPATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY / <br /> NELSON READY MIX CONCRETE&ROCK ( ) 01 FED ( ) 02 STATE f ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> P.O BOX 577 RIPON CA 95366 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/ PER Z OR <br /> NELSON READY MIX CONCRETE & RO <br /> STPEET ADDRESS NEAREST CROSS STREET <br /> J k-c4c-roA/t �- 4 <br /> CITY COUNTY ZIP <br /> crn�o SAN JOAQUIN <br /> MAILING ADDRESS CSTY <br /> STATEZIP <br /> P.O. BOX 577 RIPON CA 95366 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-599-4205 ( ) 01 GASOLINE STATION (X) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> �Z <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 /> 209-599-4205 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1973 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS f 1 UNKNOWN E. DOES THE CONTAINER STORE: [ ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM (XI 04 DIESEL ( 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE [ ) INCHES ( ) CM (X) UNKNOWN <br /> B. f l 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X1 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED f 1 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL f ) 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) .06 ALUMINUM (X) 07 STEEL CLAD ( 108 BRONZE f 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> f ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> e <br />