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seX4� <br /> +�/; � STATE ID NUMBER O000000 <br /> APPLICATI L� l�G ERATE UNDERGROUND STORAGE TANK <br /> fK101 NEW PERMIT ( ) 05 RENEWED PERMIT '4 07 TANK CLOSED f 09 DELETE FROM FILE IND FEEL <br /> 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT MINOR CHANG (NO SURCHARG <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> GEORGE KISHIDA iM8•K, ( 1 01 FED ( 102 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATC 2IP <br /> a TES-AGNERMAN"BRp7qlQ LODE CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> GEORGE KISHIDA INC GEORGE KISHIDA JR <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 240 W L9WFR-SACq#WEfFFB LXrocicpfj. C <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILINS ACCPESS CITY STATE ZIP <br /> 17 ZS G LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-368-0603 ( ) 01 GASOLINE STATION (X) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 1 <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 /> KISHIDA, GEORGE JR 209-368-0603 SAME Sw-L— 36l�000 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1X1 01 TANK ( l 04 OTHER: CONTAINER NUMBER �� <br /> 6 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 4 <br /> C. YEAR INSTALLED ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 500 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: t Y 01 WASTE 9�J_02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM (?0 C4 DIESEL < ) 05 WASTE OIL ( l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 3/16 ( ) GAUGE (X) INCHES ( ) CM ( ) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 HON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED IX) 02 SINGLE WALLED f ) 03 LINED <br /> 0. (X) 01 CARBON STEEL f ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( 1 07 STEEL CLAD l ) 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> r <br />