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APPLICATION FOR PER -- <br /> STATE ID NUMBER ' <br /> `J1 01 NEW PERMIT MIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (I 1 ( ) 05 RENEWED PERMIT <br /> 02 CONDITIONAL PERMIT <br /> [ l 06 AMENDED PERMIT ( ) 07 TANK CLOSED <br /> ( ) 08 MINOR CHANGE (NO SURCHARGE)) 09 DELETE FROM FILE (NO FEE) <br /> I OWNER <br /> N.AME(CORPORATION,INDIVIDUAL CR PUBLIC AGENCY) <br /> LODI IRON WORKS. INC. <br /> sTPEEr AaaPE5S <br /> PUBLIC AGENCY ONLY <br /> [ ) <br /> 1029 S. SCHOOL STREET crrr OI FED ( 1 02 STATE f ) 03 LOCAL <br /> LODI STATE ZIP <br /> I I F A C I L I T Y CA 95240 <br /> FACILITY NAME <br /> LODI IRON WORKS. INC.. <br /> DEA R/FO.EMAN/SUPERVISOR <br /> STREET A.DDPESS <br /> SfHBQt�STRC � _ NEAREST CROSS STREET <br /> CITY i'0./1'Ieli© -s PARK <br /> LODI <br /> COUNTY <br /> MAILING ADDRESS SAN JOAQUIN ZIP <br /> P.O. BOX ,7} tKb CITY 95240 <br /> PHONE W/APEA CODE LODI STATE ZIP <br /> 209-368-5395 TlPE OF BUSINESS CA 95240 <br /> NUMBER OF CONTAINERS ( ) 01 GASOLINE STATION (X) 02 OTHER FOUNDRY <br /> -k, <br /> PUPAL AREAS ONLY ; TOWNSHIP <br /> ��" RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LA.ST NAME FIRST) AND PHONE W/AREA CODE <br /> VAN STEENBERGE, KEVIN 209-368-5395 NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/APEA CODE <br /> VAN STEENBERGE, KEVIN 209-368-7240 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK f ) 04 OTHER: - <br /> CONTAINER NUMBER #1 <br /> 9. MANUFACTURER (IF APPROPRIATE): <br /> YEAR MFG: C. YEAR INSTALLED <br /> (X 7 (JNKNOWN <br /> t. <br /> CONTAINER ckP.aeiTY: 1000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE <br /> DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 02 PRODUCT <br /> (xl 01 UNLEADED 4" 02 REGULAR ( J 03 PREMIUM t ) 04 DIESEL f ) S WASTE OIL ( ) 06 OTHER <br /> (EL O1 YES ( ) 02 IL IF YES CHECK APPROPRIATE BOX(ES): <br /> CONTAINER CONSTRUCTION <br /> TNICi;fJESS OF PRIMARY CONTAINMENT: 12 <br /> (X) GAUGE ( ) INCHES ( ) CM ( ) UNKNOWN <br /> ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED f ) 03 UNKNOWN <br /> ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( 1 03 LINED <br /> (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> ( 1 N ALUMINUM ( ) 07 STEEL CLAD f 1 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN [ ) 13 OTHER: .RETE <br /> 14-070185 (10/18/85) <br /> PAGE I <br /> J <br />