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STATE ID NUMBER 00000016663002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) O1 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION,INOIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> MCCORMICK AND BAXTER CREOSOTE ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 6900 N EDGEWATER PORTLAND OR 97203 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> MCCORMICK AND BAXTER CREOSOTIN BILL FEGLEY <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1214 W. WASHINGTON STREET PERSHING <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95203 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P.O. BOX 1728 STOCKTON CA 95201 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-465-5767 ( ) 01 GASOLINE STATION (X) 02 OTHER WOOD PRESERVATION <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 19 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEf LF ST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> SHTBA. LARRY 209-465-5767 SHIBA, LARRY 209-465-5767 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. f ) 01 TANK (X) 04 OTHER: SUMP CONTAINER NUMBER 002 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS (X) UNKNOWN E. DOES THE CONTAINER STORE: f ) 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 t ) 04 DIESEL l ) 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( l GAUGE ( 1 INCHES ( ) CM (X1 UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ) 01 DOUBLE. WALLED ( 1 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE (X) 05 CONCRETE <br /> ( ) 06 ALUMINUM f ) 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE ( ] 10 NON-METALLIC <br /> f 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> i � <br />