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�v .ESTATE I0 NUMBER 00000064217005 <br /> APPLICATION FOR PERMIT TO OPRATE UNDERGROUND STORA TANK <br /> l 1 <br /> 01 NEW PERMIT ( 1 05 RENEWED PERMIT 0/) 07 TANK CLOSED ( 09 DELETE FROM FILE IND FEE) <br /> 1 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT 1 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> HAME(COPPORATION.INDIVIDUAL OR PUBLIC <br /> AGENCY) PUBLIC AGENCY ONLY <br /> WA'vaK* F TMA/ �- O.f 8 ( 1 01 FED ( 1 02 STATE 1 ) 03 LOCAL <br /> STREET ADDRESS ^ � CITY STATE ZIP <br /> 1dJ 5 S MANTECA CA 95336 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERV13OR <br /> H#M(MA-TEXACO aeNkt&-"-.-Krrmym K <br /> STPE!T ADDRESS NEAREST CROSS STREET <br /> 941 E. YOSEMITE AVE. POWERS AVE. <br /> CITY COUNTY IZIP <br /> MANTECA SAN JOAQUIN 95336 <br /> MAILING ADDRESS CITY STATE 2IP <br /> 941 E. YOSEMITE AVE. MANTECA CA 95336 <br /> PHONE W/AREAD[ TYPE OF BUSINESS <br /> 1- <br /> !BL2L.52A rXo ) 3 �3 '��� (X) 01 GASOLINE STATION l ) 02 OTHER <br /> NUMBER OF CONTAINERSRURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 5 I I j <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMI(LAST NAME FIRST) AND PHONE W/AREA CODE NZGHT S: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> 2B9-$23_.2906 _ - <br /> BPL-3- 3 <br /> /COM Pf E T E THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 5 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 300 GALLONS ( I UNKNOWN E. DOES THE CONTAINER STORE: (X) 01 WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED l 1 02 REGULAR f 1 03 PREMIUM 1 ) 04 DIESEL (X) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: l 1 GAUGE [ 1 INCHES ( ) CM 1X1 UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. i 1 01 DOUBLE NULLED l 1 02 SINGLE WALLED l ) 03 LINED <br /> D. ( ) 01 CARBON STEEL l 1 02 STAINLESS STEEL 1 ] 03 FIBERGLASS l 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( 109 COMPOSITE ( 1 10 NON-METALLIC <br /> (X) 12 LWHOWN ( ) 13 OTHER: <br /> ISC04-070185 (10/18/85) PAGE 1 <br /> v w/ <br />