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• • STATE ID NUMBER 00000001964003 <br />APPLICATION FOR PERMIT TO OPERATE 11NnFRr,Rn((un QTnDAr_C TAAtV <br />I I OWNER <br />JAMEfCORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />JSA PETROLEUM COMPANY ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />ZIP <br />:T REET ADDRESS CITY <br />°.0. BOX 1839 SANTA MONICA CAATE 90406 <br />II FACILITY <br />FACILITY NAME <br />NAME FIRST) AND PHONE W/AREA CODE <br />( ) GAUGE (X) INCHES <br />DEALER/FOREMAN/SUPERVISOR <br />NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />_( <br />01 NEW PERMIT <br />f 1 05 <br />RENEWED <br />PERMIT <br />( ) 07 <br />TANK CLOSED ) 09 DELETE FROM FILE (NO FEE) <br />02 CONDITIONAL PERMIT <br />( ) 06 <br />AMENDED <br />PERMIT <br />( ) 08 <br />MINOR CHANGE (NO SURCHARGE) <br />I I OWNER <br />JAMEfCORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />JSA PETROLEUM COMPANY ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />ZIP <br />:T REET ADDRESS CITY <br />°.0. BOX 1839 SANTA MONICA CAATE 90406 <br />II FACILITY <br />FACILITY NAME <br />NAME FIRST) AND PHONE W/AREA CODE <br />( ) GAUGE (X) INCHES <br />DEALER/FOREMAN/SUPERVISOR <br />NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />USA PETROLEUM COMPANY <br />#65 <br />YEAR MFG: <br />e42X +ETTIT 6y0J,>n <br />z��x-vzsZ <br />STREET ADDRESS <br />Z_0i <br />E. DOES THE CONTAINER STORE: ( <br />NEAREST CROSS STREET <br />F. -DOES <br />2500 W. LODb ell <br />IF YES CHECK APPROPRIATE BOX(ES): <br />) 06 OTHER <br />POLYVINYL CHLORIDE f 7 05 CONCRETE <br />( ) 10 NON-METALLIC <br />LOWER SACRAMENTO <br />CITY <br />COUNTY <br />2IP <br />LODI <br />SAN JOAQUIN <br />95240 <br />MAILING ADDP,ESSt <br />t <br />CITY �yO( <br />STATE <br />ZIP %'SL VQ <br />P.OOX1. Bq 25a -)25a -)CP <br />, 1-00,',40e, <br />SAWT�-rMQN=, <br />CA <br />PHONE W/AREA CODE <br />TYPE <br />OF BUSINESS <br />2)L-nI. -�3 Zvy 333983(/ <br />(X) <br />01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER OF CONTAINERS' <br />RURAL AREAS <br />.ONLY : <br />TOWNSHIP <br />RANGE <br />SECTION <br />3 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAMEfLAST <br />NAME FIRST) AND PHONE W/AREA CODE <br />( ) GAUGE (X) INCHES <br />NIGHTS: <br />NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />B. <br />-,3i'Se629='43B3 <br />YEAR MFG: <br />SAME <br />z��x-vzsZ <br />�� <br />�VIv - <br />Z_0i <br />E. DOES THE CONTAINER STORE: ( <br />"--efl'1PLETE THE FOLITMING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01TANK( ) 04 OTHER: <br />( ) GAUGE (X) INCHES <br />CONTAINER <br />NUMBER 3 <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />C. <br />YEAR INSTALLED 1971 ( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: 12000 GALLONS ( 1 UNKNOWN <br />E. DOES THE CONTAINER STORE: ( <br />) 01 WASTE (X) 02 PRODUCT <br />F. -DOES <br />THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO <br />( ) 01 UNLEADED ( ) 02 REGULAR (X) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( <br />IF YES CHECK APPROPRIATE BOX(ES): <br />) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY CONTAINMENT: 1/4" <br />( ) 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 />01 <br />DOUBLE WALLED (X) 02 SINGLE WALLED ( <br />) 03 LINED <br />D. <br />(X) 01 <br />( '06 <br />( 1 12 <br />CARBON STEEL ( 7 02 STAINLESS STEEL <br />ALUMINUM f 1 07 STEEL CLAD ( ) 08 <br />UNKNOWN ( ) 13 OTHER: <br />( 1 03 F15ERGLASS ( ) 04 <br />BRONZE ( ) 09 COMPOSITE <br />POLYVINYL CHLORIDE f 7 05 CONCRETE <br />( ) 10 NON-METALLIC <br />,6u.64-u/uioD C10/lt3/tl5P <br />0 <br />PAGE 1 <br />