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1.40 <br /> STATE ID NUMBER 00000058162001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> Un 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPOPATION.INOIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> LODI UNIFIED SCHOOL DISTRICT ( ) 01 FED ( ) 02 STATE (,kf 03 LOCAL <br /> STREET ADDRESS CITY STATE IIP <br /> 815 WEST LOCKEFORO ST. LORI CA 95240 <br /> II FACILITY <br /> FACILITY NAMES D DEALER/FOREMAN/SUPERVISOR ({ <br /> MAINTENANCE 4 OPERATIONS YARD LEN FISCHER ,r, p o�- '�� lZl:fti <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 31 NORTH PACIFIC AVE. ELM STREET <br /> CITY COUNTY <br /> ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS [n-�/ CITYZIP <br /> F(/s R/ L(/GlLe7�( 1/ SLODI CAATE 95240 <br /> PMO NE W/AREA CODE TYPE OF BUSINESS �" / <br /> 209-369-1242 WK 01 GASOLINE STATION (A 02 OTHER 5;I.A.10 <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 3 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> FISCHER, LEONARD 209-369-1242 FISCHER. LEONARD 209-333-1565 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X1 01 TANK ( ) 04 OTHER: CONTAINER NUMBER M @ O W04 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1958 C. YEAR INSTALLED 1958 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 1000 GALLONS ( ) UNKNOWN I E. DOES THE CONTAINER STORE: CA-r 01 WASTE OR 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 f ) 02 REGULAR ( ) 03 PREMIUM CM 04 DIESEL (4 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( l INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( 1 03 LINED <br /> D. (X) 01 CARBON STEEL ( l 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE [ l 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> WSW <br />