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• • STATE ID NUMBER 00000062513004 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPOR.ATION,INDIVIDUA^L, '.OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> GisguRGH U.S.A. C.�u.s,�l,(N, )e, m &12 ,S ( 1 01 FED f ) 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS - CITY STATE IIP <br /> �TM� ) D3 oL S . C a 5 sAH FRAHeIsco /7� � cA <br /> II FACILITY <br /> FACILITY Nq�E .p DEALER/FOREMAN/SUPERVISOR <br /> 1Jre the rs ��,V r�`�\ 93 <br /> J 0a 3 BRESHEARS>C M <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 824 E. YOSEMITE AVE. POWERS <br /> CITY COUNTY <br /> ZIP <br /> MANTECA SAN JOAQUIN 95336 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 824 E. YOSEMITE AVE. .MANTECA CA 95336 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-823-5717 (X) 01 GASOLINE STATION ( ) 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 /> 44 Aro s - &OR2 8.23 - sl Y9 <br /> resears ,Ia,. l a cr a 3 - 71 <br /> COMPLETE THE FO WING ON A SEPARATE FORM FOR EACH CONTAIN-ER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 4 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1965 C. YEAR INSTALLED 1965 [ 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 550 GALLONS f ) UNKNOWN E. DOES THE CONTAINER STORE: (X) 01 WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL I ( ) O1 YES f ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) <br /> 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM i ) 04 DIESEL WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 0000100 [ 1 GAUGE ( ) INCHES ( ) CM ( ) 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 ( 1 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL f ) 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE f 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN f ) 13 OTHER: <br /> HSC04-070185 (30/18/85] PAGE 1 <br />