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STATE ID NUMBER 00000063780002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) <br /> 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> ELWOOD ALBERG [ ) 01 FED ( 1 02 STATE f 1 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 2005 JERRY-LANE LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> DELTA PUT I GAS <br /> STREET ADDRESS NEAREST CROSS STREET _ <br /> 13430 N LOWER SAC RD HARNEY LANE <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 13430 N LOWER SAC RD LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-474-9449 (X) 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 2 <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 /> RYAN EDWARD 209-474-9449 SAME ' <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ] 04 OTHER: CONTAINER NUMBER I <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS (X) UNKNOWN E. DOES THE CONTAINER STORE: l 1 01 WASTE (X) 0.2 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 /> (X) 01 UNLEADED f ) 02 REGULAR ( 1 03 PREMIUM ( 1 04 DIESEL f ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> 0 <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 7 INCHES ( 1 CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED E 1 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( ) 01 CARBON STEEL ( 7 02 STAINLESS STEEL [ ) 03 FIBERGLASS f ] 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> f ) 06 ALUMINUM f 7 07 STEEL CLAD f ) 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ' (X) 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />