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AwSTATE 10 NUMBER 00000034786002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT (V'07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> f ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPOPATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> WILLIAM BURKHARDT ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STPEET ADDRESS CITY STATE ZIP <br /> 5154 HOGAN LANE LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> WILLIAM BURKHARDT <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 5154 HOGAN. LANE Ai, lityl R 9 � UYl <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADCPESS CITY STATE ZIP <br /> 5154 HOGAN LANE LODI CA 95240 <br /> PHONE W/APEA CODE TYPE OF BUSINESS <br /> 01 GASOLINE STATION (X) 02 OTHER FARM "S4aiNG <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 2 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> GAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> NIGHTS: NAME(lAST NAME FIRST) AND PHONE W/AREA CODE <br /> BURKHARDT,Oft gjtaC, x"0'4-ZO CI-3(��III .SAME - - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (XI 01 TANK ( ) 04 OTHER: CONTAINER NUMBERZ/ <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1965 f ) UNKNOWN <br /> D. CONTAINER CAPACITY: *0 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) Ol YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED (><f 02 REGULAR ( ) 03 PREMIUM k)0'04 DIESEL ( 1 05 WASTE OIL ( l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( 1 GAUGE l ) INCHES ( ) CM (X) UNKNOWN <br /> B. f 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 MON-VAULTED ( 1 03 UNKNOWN <br /> C. f ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED t ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ] 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( 110 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> MSC04-070185 (10/18/85) PAGE 1 <br /> u � <br />