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r <br /> k - • STATE ID NUMBER 00000029713001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> Et01 NEW PERMIT ( ) 05 RENEWED PERMIT (X 07 TANK CLOSED \`�J 09 DELETE FROM FILE (NO FEEL <br /> 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT f ) 08 MINOR CHANGE (NO SURCHARGEi <br /> I X OWNER <br /> NAME(COPFOFATIDN.INOIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> R K-'4-R-FT+T-lMi•t � f 7 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> MTJ-1EET AO <br /> OS7Y STATE IIP <br /> �) CA 953a <br /> II FACILITY <br /> F=CILITY NAME �,� fruif Pik �. <br /> DEALE FOREMAN/SUPERVISOR <br /> ... moi.:-v�IT€T4)ti. <br /> STFEET ADDRESS NEAREST CROSS STREET <br /> 19901 SO. MCHENRY AVENUE CLOUGH AVENUE <br /> CITY COUNTY ZIP <br /> ESCALON SAN JOAQUIN 95320 <br /> MAILING ADDRESS CITY <br /> P.O. BOX 67 STATE ZIP <br /> JESCALON CA 95320 <br /> PHCNE W/APEA CODE TYPE OF BUSINESS <br /> 209-838-3564 ( ) 01 GASOLINE. STATION (X) 02 OTHER FRESH FRUIT PROCESSI <br /> NUY.BER 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 /> MAR�iH-tkF-i1R('�* 209-838--389.4 <br /> -c'89 838 58.69 <br /> a <br /> 7-ZY,TZ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR 'MFG: 1978 C. YEAR INSTALLED 1978 ( 1 UNKNOWN <br /> Z214?le/ <br /> 0. CONTAINER CAPACITY: 8000 GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ®01 YES 00 02 NO IF YES CHECK APPROPRIATE SOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL f ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( 1 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( 7 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> ( ) 06 ALUMINUM (X) 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE [ 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) <br /> PAGE 1 <br /> v <br />