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`../ STATE ID NUMBER 00000054801001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ! ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( 1 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( 106 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPOR ATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> GAS N SAVE ( ) 01 FED f ) 02 STATE f ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 16 S. CHEROKEE LANE LOBI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> GAS N SAVE <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 16 S. CHEROKEE LANE <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 16 S. CHEROKEE LANE LODI CA 95240 <br /> PHONE W/APER CODE TYPE OF BUSINESS <br /> 209-334-9869 (X) 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER. OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 3 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME[LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: N4ME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> 209-334-9869 - - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TAM( ( ) 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 6000 GALLONS ( ) UNKNOWN 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 /> ( ) 01 UNLEADED ( 1 02 REGULAR (X) 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. [ ) 01 DOUBLE WALLED ( 1 02 SINGLE WALLED ( ) 03 LINED <br /> D. l ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE f 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />