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10 <br /> STATE IO NUMBER 00000058305001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1101 NEW PERMIT ! ) 05 RENEWED PERMIT ( 1 07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( l 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CC'FRCFATICN,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> EAST BAY MUNICIPAL UTILITY DISCI t l 01 FED ( 1 02 STATE [ l 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> P.O. BOX 158 CLEMENTS CA 95227 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> MOKELUMNE RIVER FISH lWTAtL*T-R <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 23024 NO. MCINTIRE ROAD HIGHWAY 12 <br /> CITY COUNTY ZIP <br /> CLEMENTS SAN JOAQUIN 95227 <br /> MAILIN3 ADDRESS CITY STATE ZIP <br /> P.O. BOX 158 CLEMENTS to 95227 <br /> PHONE W/APEA CODE TYPE OF BUSINESS <br /> 209-759-3383 f 1 01 GASOLINE STATION (X1 02 OTHER AQUACULTURE <br /> NUMEEO OF CONT4_NEPS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> 1 4N 9E 6 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS? NAM (LAST NAME FIRST) AND PHONE W/,AREA CODE NIGHTS: NAME( L.AST NAME FIRST) AND PHONE WiAREA COD <br /> 209-759-3383 209-75.9-3383 <br /> COMPLETE THE FOLL014ING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CCHTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> 0. CONTAINER CAPACITY: 550 GALLONS F 1 UNKNOWN JE. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 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 /> (X) 01 UNLEADED [ ) 02 REGULAR ( ) 03 PREMIUM ( l 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> v CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT= t ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> 0. ()C) 01 CARBON STEEL ( l 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLCRIDE ( ) 05 CONCRETE <br /> f ) 06 ALUMINUM f l 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE ! 1 10 NON-METALLIC <br /> W.) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />