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`oe 11 STATE ID NUMBER 00000012520003 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (lG 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> T-J 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> LANCE ELLIS ( ) 01 FED f ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 820 S. CHEROKEE LN LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> ELLIS CAR WASH ee t'E? <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 820 S. CHEROKEE VINE <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 820 S. CHEROKEE L00I CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-333-1334 (X) 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 4 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAME(LAST NAME FIRST) AND PHONE W/AP.EA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> LANCE, ELLIS 209-333-1334 LANCE ELLIS 209-164-3831- <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 002 <br /> B. MANUFACTURER (IF APPROPRIATE): ?????????????????????????????? YEAR MFG: 1972 C. YEAR INSTALLED 1972 ( l UNKNOWN <br /> D. CONTAINER CAPACITY: 5000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: f ) 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 /> f ) <br /> 01 UNLEADED ( l 02 REGULAR (X) 03 PREMIUM ( ) 04 DIESEL l ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ??????? f ) GAUGE f ) INCHES ( ) CM (XI UNKNOWN <br /> S. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( 1 03 LINED <br /> 0. 1 ) 01 CARBON STEEL ( 102 STAINLESS STEEL f ) 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE l ) 05 CONCRETE <br /> [ ) 06 ALUMINUM l 1 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE l ) 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> KSC04-070185 (10/18/85) PAGE 1 <br />