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0 0 <br />STATE ID NUMBER 00000001964002 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />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 SURCHARGE) <br />II OWNER <br />NAME(COPPCPATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />USA PETROLEUM COMPANY ( ) 01 FED ( ) 02 STATE ( 1 03 LOCAL <br />S TPEET ADDRESS CITY STATE ZIP <br />P.O. BOX 1839 SANTA MONICA CA 90406 <br />I II FACILITY <br />FACILITY NAME <br />24 HOUR EMERGENCY <br />CONTACT PERSON <br />DEALER/FOREMAN/SUPERVISOR <br />B. <br />USA PETROLEUM COMPANY 065 <br />NAME(LAST NAME FIRST) AND <br />PHONE W/AREA CODE <br />G RX T`T <br />NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />STREET ADDRESS <br />MARK-EBNfkHi 215 __9 <br />.__3 <br />NEAREST CROSS STREET <br />SAME 30- yZ,-,Y2_ <br />2500 W. LODI et(p(/• <br />L <br />a3J V <br />LOWER SACRAMENTO <br />CITY <br />FC #J NG ON A <br />SEPARATE FORM FOR EACH CONTAINER <br />COUNTY <br />DESCRIPTION <br />ZIP <br />LODI <br />SAN JOAQUIN <br />95240 <br />MAILING ADDRESS <br />CITY CAbl <br />STATE <br />Q �/ <br />ZIP IS 2 T U <br />�rp^gg)F q 'zSfjd <br />�- <br />SANT► MM'l9"� <br />CA <br />90466 <br />PHONE W/AREA CODE <br />TYPE OF BUSINESS <br />23(XI <br />01 GASOLINE STATION ( 1 02 OTHER <br />NUMBER OF CONTAINERS <br />RURAL <br />AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />3 <br />III <br />24 HOUR EMERGENCY <br />CONTACT PERSON <br />CONTAINER NUMBER 2 <br />B. <br />DAYS: <br />NAME(LAST NAME FIRST) AND <br />PHONE W/AREA CODE <br />D. <br />NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />E. DOES THE <br />MARK-EBNfkHi 215 __9 <br />.__3 <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) <br />( ) 01 UNLEADED (X) 02 REGULAR f 1 03 PREMIUM ( ) 04 DIESEL <br />SAME 30- yZ,-,Y2_ <br />r,� <br />L <br />a3J V <br />48i4PLETE THE <br />FC #J NG ON A <br />SEPARATE FORM FOR EACH CONTAINER <br />IV <br />DESCRIPTION <br />A. <br />(X) 01 TANK ( ) 04 OTHER: <br />) CM ( ) UNKNOWN <br />CONTAINER NUMBER 2 <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />I C. YEAR INSTALLED 1971 ( 1 UNKNOWN <br />D. <br />CONTAINER CAPACITY: 12000 GALLONS ( 1 UNKNOWN <br />E. DOES THE <br />CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) <br />( ) 01 UNLEADED (X) 02 REGULAR f 1 03 PREMIUM ( ) 04 DIESEL <br />01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOXIES): <br />( ) 05 WASTE OIL ( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: 1/4" ( ) GAUGE (X) INCHES ( <br />) CM ( ) UNKNOWN <br />B. <br />( 1 01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) 01 <br />DOUBLE WALLED (X) 02 SINGLE WALLED f l 03 LINED <br />D. <br />fX) 01 <br />f ) <br />( ) 12 <br />CARBON STEEL ( l 02 STAINLESS STEEL ( ) 03 FIBERGLASS f ) 04 <br />06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ] 09 COMPOSITE <br />UNKNOWN ( ) 13 OTHER: <br />POLYVINYL CHLORIDE ( 1 05 CONCRETE <br />( 1 10 NON-METALLIC <br />t HSC04-070185 (10/18/85) <br />PAGE 1 <br />