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,K r-*k " STATE ID NUMBER 00000021195002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED 09 DELETE FROM FILE (NO FEE)] <br /> ( l 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) MINOR CHANGE (NO SURCHAR <br /> I OWNER <br /> NAME(COPPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> BILL 0. FOUST, SR. 1JP (Al ( ) 01 FED ( l 02 STATE �) 03 LOCAL <br /> STREET ADORESS l CITY STATE ZIP <br /> 1157 NORTH HAM LANE ` LOOI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> AMERICAS( INC. <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 840 N. SACRAMENTO STREET TURNER ROAD <br /> CITY COUNTY <br /> ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITYSTATE ZIP <br /> P.O. BOX 267 LODI 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 POWER, DON 209-369-5922 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( 1 01 TANK (X) 04 OTHE : SUMP CONTAINER NUMBER 2 <br /> S. MANUFACTURER (IF APPROPRIATE): N/A YEAR MFG: 1975 C. YEAR INSTALLED 1975 ( ] UNKNOWN <br /> 0. CONTAINER CAPACITY: GALLONS (X) UNKNOWN E. DOES THE CONTAINER STORE: (X) 01 WASTE ( ) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? ( ) 01 YES (X) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f ) 01 UNLEADED ( ] 02 REGULAR ( 1 03 PREMIUM f ) 04 DIESEL f ! 05 WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( I GAUGE f 1 INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) IX) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. t ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> 0. ( 1 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE (X) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE [ ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> STATE ID NUMBER 00000021195002 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING f l 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f 1 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE f 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 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 BOXES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN l l 07 NONE <br /> VII LEAK DETECTION <br /> (X) 01 VISUAL f ) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( l 05 SENSOR INSTRUMENT <br /> ( ] 06 GROUND WATER MONITORING WELLS ( 1 07 PRESSURE TEST ( ) 09 NONE [ ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECEEO 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 /> STORED STORED <br /> ( l Ol ( ) 02 ( l 03 <br /> ( l 01 ( ) 02 C ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) Ol ( ) 02 l 1 03 <br /> ( ) <br /> al ( ) 02 I 1 03 <br /> f 1 01 ( ) 02 ( ) 03 <br />