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o ,STATE ID NUMBER 00000016663004 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STO AGE TANK <br /> ( 1 01 14EW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED v 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT f ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COP,PORATION.INDIVIDUAL OR PUBLIC AGENCY ) PUBLIC AGENCY ONLY <br /> MCCORMICK AND BAXTER CREOSOT9W6- ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET AGGRESS CITY STATE ZIP <br /> 6900 N EDGEWATER PORTLAND OR 97203 <br /> II FACILITY <br /> FACILITY N4111E DEALER/FOPEMAN/SUPERVISOR <br /> MCCORMICK AND BAXTER CREOSOTINS BILL FEGLEY/ P{Q&+ Mgt, <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/APER CODE TYPE OF BUSINESS <br /> 209-465-5767 ( ) 01 GASOLINE STATION (X) 02 OTHER WOOD PRESERVATION <br /> URAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 19 NUMBED OF CONTAINERS R <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 /> SHIBA, LARRY 209-465-5767 SHIBA, LARRY 209-465-5767 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION J _ <br /> AeX _JC <br /> A. L.M701 TANK U(1 04 OTHER Sp�O,XEIT�f CONTAINER NUMBER 004 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS (X) UNKNOWN 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 BOX(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: 1/8" f ) GAUGE (X) INCHES ( ) CM ( ) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) [ ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED ( ) 02 SINGLE WALLED (X) 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( l 04 POLYVINYL CHLORIDE (X) 05 CONCRETE <br /> [ ) 06 ALUMINUM f ) 07 STEEL CLAD f l 08 BRONZE f 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />