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STATE ID NUMBER 00000058737002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 1 <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> f ) 02 CONDITIONAL PERMIT f 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (ND SURCHARGE) <br /> I OWNER <br /> NAME(CORPOP.ATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ELWOOD ALBERG ( ) O1 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 1343 N. LOWER SAC. RD. LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> DELTA PUB & GROCERY <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 13430 LOWER SAC. RD. HARNEY LANE <br /> CITY COUNTY 'ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDPESS CITY STATE ZIP <br /> 13430 LOWER SAC. RD. LODI CA 95240 <br /> PHONE W/AREA CODE TYPEOF BUSINESS <br /> 209-368-9232 (X) 01 GASOLINE STATION f ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSXI P. RANGE SECTION <br /> 2 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMEf LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> RYAN EDWARD 209-368-9232 RYAN, EDWARD 209-474-9449 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 2 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS (X) UNKNOWN E. DOES THE CONTAINER STORE: f 1 01 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 (X1 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: [ ) GAUGE f ) INCHES ( ) CM (X) UNKNOWN <br /> B. (X) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ) 03 LINED <br /> D. f ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM f ) 07 STEEL CLAD ( ) 08 BRONZE ( 1 09 COMPOSITE ( l 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />