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LlK X977 <br /> r'STATE ID NUMBER 00000021195003 <br /> �p/s7MaE G�[`kr/ <br /> APPLICATION FOR PERM T R ND STORAGE TANK <br /> ( ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 09 DELETE FROM FILE (140 FEE) <br /> ( 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO) SURCHARGI <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> BILL 0. FOUST, SR. ( ) 01 FED ( ) 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 1157 NORTH HAM LANE LOOI CA 95240 <br /> II FACILITY a. <br /> FACILITY NAME DEALER/FOR MAN/SUPX.RVISOR <br /> AMERIGAS, INC. /GL �� • �f y � � <br /> STPEET ADDPESS NEAREST CROSS STREET <br /> 840 N. SACRAMENTO STREET TURNER ROAD <br /> CITY COUNTY ZIP <br /> LODI SAN UOAQUIN 95240 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P.O. BOX 267 LO)DI CA 95241 <br /> PHONE W/APIA CODE TYPE OF BUSINESS <br /> 209-334-1014 ( ) 01 GASOLINE STATION (X) 02 OTHER <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/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> POWER, DON 209-334-1014 POWERS DON 209-369-5922 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 3 <br /> S. MANUFACTURER (IF APPROPRIATE): PERKINS WELD YEAR MFG: 1977 C. YEAR INSTALLED 1977 f ) UNKNOWN <br /> IvU.1rb7 <br /> D. CONTAINER CAPACITY: 550 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: f ) 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 (X) 02 REGULAR ( ) 03 PREMIUM ( l 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 10 (X) GAUGE f ) INCHES ( ) CM ( 1 UNKNOWN <br /> B. ( ] 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 101 DOUBLE WALLED (X) 02 SINGLE WALLED f ) 03 LINED <br /> D., (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM f 1 07 STEEL CLAD ( 1 08 BRONZE ( ] 09 COMPOSITE ( 1 30 NON-METALLIC <br /> f l 12 UNKNOWN ( ] 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> V <br /> STATE ID NUMBER 00000021195003 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYO LINING ( ) 03 EPDXY LINING l 1 04 PHENOLIC LINING f ] 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING f ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( ) 05 NONE <br /> (X) 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f l 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE (X) 05 SUCTION ( 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS [ ] 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STOPED STOPED <br /> ( ) 01 ( 102 ( ) 03 <br /> ( 1 <br /> al f 1 02 ( ) 03 <br /> ( 1 Ol f 1 02 ( ) 03 <br /> f 1 01 ( ) 02 ( 1 03 <br /> f ) Ol ( ) 02 ( 1 03 <br /> ( I <br /> al ( ] 02 ( 1 03 <br /> f i <br /> 01 ( 1 02 ( 7 03 <br /> l 1 01 ( 1 02 ( ) 03 <br />