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STATE ID NUMBER 00000034936001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT jyi.07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT ( l 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAMECCORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CITY OF LODI ( 1 01 FED f 1 02 STATE (X 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 221 W. PINE ST. LOOT CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> WELL 16 FRAN E. FORKAS <br /> STREET ADDRESS NEAREST CROSS STREET <br /> WEST END OF CENTURY BLVD. <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITYSTATE ZIP <br /> 1331 SO. HAM LN LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-333-6740 ( 1 O1 GASOLINE STATION (X) 02 OTHER WATER WELL <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 1 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMECLAST NAME FIRST) AND PHONE W/AREA COOK NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> UTILITY OPERATORSa09-3&o - UTILITY OPERATOR 209-368-5735 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 16 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 350 GALLONS f 1 UNKNOWN I E. 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 /> ( l 01 UNLEADED f 1 02 REGULAR ( 1 03 PREMIUM (X) 04 DIESEL f ) 05 WASTE OIL f l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1/4 ( 1 GAUGE (X) INCHES ( ) CM ( 1 UNKNOWN <br /> S. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( 1 03 LINED <br /> D. (X) 01 CARBON STEEL f ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE ( ] 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( l 08 BRONZE ( 1 09 COMPOSITE f l 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />