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STATE ID NUMBER 00000021195001 <br /> APPLICATION FOR PERMIT TO OPERAT DERGROUND STORAGE TANK <br /> ( 1 01 NEW PERMIT f 105 RENEWED PERMIT D ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT ( l 06 AMENDED PERMIT ? 408 MINOR HA E (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) { PUBLIC AGENCY ONLY <br /> BILL 0. FOUST, SR. fi4\ ( ] Ol FED ( 1 02 STATE 1 1 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 115T_HORTH HAM LANE LODI CA 95240 <br /> i <br /> II FACILITY ( lc <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> AMERIGAS. INC. <br /> STP19T ADDRESS NEAREST CROSS STREET <br /> 840 N. SACRAMENTO STREET TURNER ROAD <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 1 95240 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P.O. BOX 267 LODI CA 95241 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-334-1014 ( 1 O1 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 POWER, DON 209-369-5922 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) Ol TANK ( ) 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): PERKIN'S WELOGING YEAR MFG: 1975 C. YEAR INSTALLED 1975 E ) UNKNOWN <br /> -puarrk) <br /> D. CONTAINER CAPACITY: 1000 GALLONS ( 1 UNKNOWN iE. DOES THE CONTAINER STORE: ( 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 (X) 02 REGULAR ( ) 03 PREMIUM 1 ) 04 DIESEL f 1 05 WASTE OIL f 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 10 (X) GAUGE ( ) INCHES ( ) CM ( ) UNKNOWN <br /> B. ( 7 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 7 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( 7 02 STAINLESS STEEL f l 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( l 08 BRONZE ( 1 09 COMPOSITE ( ] 10 NON-METALLIC <br /> ( 1 12 UNKNOWN f 1 13 OTHER: <br /> KSC04-070185 (10/18/85) PAGE 1 <br /> r1100, <br /> STATE ID NUMBER 00000021195001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING f ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP [ 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN ( 1 05 NONE <br /> (X1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( 1 01 DOUBLE-WALLED PIPE ( ] 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) l ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: f 1 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( 7 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS [ 1 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS f l 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 REgUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> 1 ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f ) 01 ( ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( 7 03 <br /> ( ) Ol ( ) 02 1 ) 13 <br />