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• • STATE ID NUMBER 00000062513002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 NEW PERMIT ( i 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY Q PUBLIC AGENCY ONLY <br /> • '�- d�-ot�hea� [ ) 01 FED f ) 02 STATE f ) 03 LOCAL <br /> STREET ADDRESS / c CITY STATE ZZP <br /> R-75'"MARK'Ei�• I q U 301- J �6� A 53 <br /> II FACILITY <br /> FACILITY AME 1_ DEALEP/FOREMAN/SUPERVISOR <br /> - ('��v\C'.0.,rS BRESHEARS,C M <br /> STREET A040C NEAREST CROSS STREET <br /> 824 E. YOSEMITE AVE. POWERS <br /> CITT COUNTY .ZIP <br /> MANTECA SAN JOAQUIN 95336 <br /> MAILING ADOPESS CITY STATE ZIP <br /> 824 E. YOSEMITE AVE. MANTECA CA 95336 <br /> PHONE W/AREA CCC- TYPE OF BUSINESS <br /> 209-823-5717 (X) 01 GASOLINE STATION f 1 02 OTHER <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 /> ' <br /> � !I 1 -1 <br /> OLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 2 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1965 C. YEAR INSTALLED 1965 ( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: ALLONS f ) UNKNOWN E. DOES THE CONTAINER STORE: ( 7 01 WASTE IX) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( 1 01 YES ( ] 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED f 1 02 REGULAR ) 03 PREMIUM ( ) 04 DIESEL f 1 05 WASTE. OIL ( 7 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 0000170 ( ) GAUGE ( ) INCHES ( ) CM ( 7 UNKNOWN <br /> B. f 101 VAULTED .(LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ] 01 DOUBLE WALLED fX) 02 SINGLE WALLED f 1 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> ( ) 06 ALUMINUM f ) 07 STEEL CLAD ( ) 08 BRONZE { ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN [ ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />