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STATE ID NUMBER 00000018101001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND <br /> f ) 01 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 SURC <br /> I OWNER <br /> NAME(COPPOPATION.INOIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> BEN MANZANO ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY <br /> 20540 DAMS RD. STATE ZIP <br /> LDOI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> BEN MANZANO <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 20540 DAVIS RD. WOODBRIDGE RD. <br /> CITY <br /> COUNTY LIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING AODPESS CITY STATE ZIP <br /> 20540 DAVIS RD. LDDI CA 95240 <br /> PHONE W/AP.EA CODE TYPE OF BUSINESS <br /> 209-333-2855 ( ) 01 GASOLINE STATION (X) 02 OTHER HOME <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 2 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> BEN MANZANO 209-333-2855 - <br /> COMPLETE THE FOLLOWING GN A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 0000000001 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 500 GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: ( ) Ol 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 (X) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1 ) GAUGE l ) INCHES ( ) CM (X) UNKNOWN <br /> B. (X) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( 1 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED 1 ) 02 SINGLE WALLED f ) 03 LINED <br /> 0. ( ) 01 CARBON STEEL l ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE l l 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD f ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> (X) 12 UNKNOWN f ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />