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v) I.?�tG STATE ID NUMBER 00000000726003 <br />APPLICATION FOR PERMIT TO OP AI UNDERGROUND••S11TORAGE TANK <br />01 NEW PERMIT ( ) 05 RENEWED PERMIT( 07 TAN S ( ) 09 DELETE FROM FILE (NO FEE) <br />{ ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />JAME(COPPCR4TION.INDI','IDU.AL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />lOORE PETROLEUM ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />>TREET ADDRESS CITY STATE ZIP <br />iTH & F ST. (P.O. BOX 67) BANTA CA 95304 <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( ) 04 OTHER <br />DEALER/FOREMAN/SUPERVISOR <br />FRANKS EXXON #2 <br />NUMBER 3 <br />FRANK GUINTA <br />STREET ADDRESS <br />1399 E. YOSEMITE AVE <br />YEAR MFG: <br />NEAREST� CROSS STREET <br />pV <br />YEAR INSTALLED (X) UNKNOWN <br />D. <br />! 0 f"+f\Ali <br />CITY <br />) 01 WASTE (X) 02 PRODUCT <br />COUNTY <br />ZIP <br />MANTECA <br />SAN JOAQUIN <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />1399 E. YOSEMITE AVE <br />MANTECA <br />CA <br />95336 <br />PHCNE W/APE.A CODE <br />TYPE OF BUSINESS <br />209-823-3313 <br />(X) 01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />4 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />)AYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREAA CODE <br />i98RE209-6-�e- MOORE, JERRY 209-9A.6 9;94C <br />u�rt �a 3-3313 tt( n r -931-3— <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( ) 04 OTHER <br />) CM ( ) UNKNOWN <br />CONTAINER <br />NUMBER 3 <br />B. <br />MANUFACTURER (IF APPROPRIATE): PERKINS <br />YEAR MFG: <br />C. <br />YEAR INSTALLED (X) UNKNOWN <br />D. <br />iollOOD <br />CONTAINER CAPACITY: Z8 GALLONS ( l UNKNOWN <br />E. DOES THE CONTAINER STORE: ( <br />) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO <br />( ) 01 UNLEADED ( ) 02 REGULAR (X) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( <br />IF YES CHECK APPROPRIATE BOX(ES): <br />) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: 1/4 ( ) GAUGE (X) INCHES ( <br />) CM ( ) UNKNOWN <br />B. <br />( ) 01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) 01 <br />DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br />D. <br />(X) 01 <br />( ) <br />( ) 12 <br />CARBON STEEL ( ) 02 STAINLESS STEEL ( l 03 FIBERGLASS ( l 04 <br />06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE <br />UNKNOWN ( ) 13 OTHER: <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 10 NON-METALLIC <br />HSC04-070185 (10/18/85) PAGE 1 <br />