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STATE ID NUMBER 00000062811001 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />d.1 -A1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />IA.ME(COPPOPATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />:HEVRON U.S.A. INC. ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />�TPEET A.DDOESS TCSANFRANCISCO <br />ITY STATE ZIP <br />;75 MARKET CA 94105 <br />II FACILITY <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />:A.YS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AP.EA CODE <br />1AINTENANCE DISPATCH 415-877-0244 'F" &p) - - <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />2 S <br />?, S7� <br />) CM ( ) UNKNOWN <br />CONTAINER <br />NUMBER <br />FACILITY NAME <br />9 ' <br />B. <br />v ror\ <br />( l 01 <br />DEALER/FOREMAN/SUPERVISOR <br />MCCOMB,ROBERT J 0 4o m iQy - <br />C. <br />STREET ADDRESS <br />/ Cj 8,3 ( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: <br />NEAREST CROSS STREET <br />E. DOES THE CONTAINER STORE: (X) 01 WASTE ( <br />301 W. KETTLEMAN LANE <br />F. <br />DOES THE CONTAINER <br />( ) 01 UNLEADED ( <br />STORE MOTOR VEHICLE FUEL OR WASTE OIL ?O1 YES ( l 02 NO <br />) 02 REGULAR ( ) 03 PREMIUM ( l 04 DIESEL (305 WASTE OIL <br />LEE <br />C:T'i <br />COUNTY <br />ZIP <br />LODI <br />SAN JOAQUIN <br />95240 <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />301 W. KETTLEMAN LANE <br />LODI <br />CA <br />95240 <br />PHONE W/'AREA CODE <br />TYPE <br />OF BUSINESS <br />209-368-8614 <br />(X) <br />01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL AREAS <br />ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />4 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />:A.YS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AP.EA CODE <br />1AINTENANCE DISPATCH 415-877-0244 'F" &p) - - <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( ) 04 <br />OTHER: <br />) CM ( ) UNKNOWN <br />CONTAINER <br />NUMBER <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />( l 01 <br />YEAR MFG: <br />C. <br />YEAR INSTALLED <br />/ Cj 8,3 ( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: <br />1000 GALLONS f ) UNKNOWN <br />E. DOES THE CONTAINER STORE: (X) 01 WASTE ( <br />) 02 PRODUCT <br />F. <br />DOES THE CONTAINER <br />( ) 01 UNLEADED ( <br />STORE MOTOR VEHICLE FUEL OR WASTE OIL ?O1 YES ( l 02 NO <br />) 02 REGULAR ( ) 03 PREMIUM ( l 04 DIESEL (305 WASTE OIL <br />IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY <br />CONTAINMENT: 0000370 ( ) GAUGE ( ) INCHES ( <br />) CM ( ) UNKNOWN <br />B. <br />( 1 01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( l 01 <br />DOUBLE WALLED <br />(X) 02 SINGLE WALLED ( ) 03 LINED <br />D. <br />( ) 01 <br />( ) <br />( ) 12 <br />CARBON STEEL <br />06 ALUMINUM <br />UNKNOWN ( ) <br />( ) 02 STAINLESS STEEL (.)..p3 FIBERGLASS ( ) 04 <br />( ) 07 STEEL CLAD ( ) OMWONZE ( ) 09 COMPOSITE <br />13 OTHER: <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 10 NON-METALLIC <br />HSC04-070185 (10/18/85) PAGE 1 <br />