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u <br /> STATE ID NUMBER 00000012520004 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> OCl <br /> 01 NEW PERMIT [ ) OS RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> l 'f 02 CONDITIONAL PERMIT f ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPCPATION,INOIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> LANCE ELLIS ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDPESS CITYSTATE ZIP <br /> 820 S. CHEROKEE LN LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/f OREMAN/SVPERVISOR <br /> ELLIS CAR WASH BEAii <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 LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-333-1334 (X) 01 GASOLINE STATION t ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 4 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CGDENIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> LANCE, ELLIS 209-333-1334 LANCE ELLIS 209.36A--i6i3 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK f ) 04 OTHER: CONTAINER NUMBER 003 <br /> B. MANUFACTURER (IF APPROPRIATE): ?????????????????????????????? YEAR MFG: 1972 C. YEAR INSTALLED 1972 ( ] UNKNOWN <br /> 0. CONTAINER CAPACITY: 4000 GALLONS ( 1 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 HO IF YES CHECK APPROPRIATE BOX(ES): <br /> t ) 01 UNLEADED ( ) 02 REGULAR (XI 03 PREMIUM ( ) 04 DIESEL f ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ??????? ( ) GAUGE f ) INCHES ( ) CM (X) UNKNOWN <br /> B. t ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( 1 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( 1 02 SINGLE WALLED ( ) 03 LINED <br /> D. ( ) 01 CARBON STEEL l ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ] 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />