Laserfiche WebLink
`/ 1.0w <br />STATE ID NUMBER 00000048482001 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />( ) <br />01 NEW PERMIT ( ) 05 RENEWED PERMIT ( 1 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(COPPORATICN.:NDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />PINEY C. KAHLER ( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />STREET ADDRESS CITY STATE ZIP <br />5113 W. SARGENT RD. LODI CA 95240 <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( ) 04 OTHER: <br />DEALER/FOREMAN/SUPERVISOR <br />CONTAINER NUMBER 1 <br />RINEY C. KAHLER <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />C. <br />STREET ADDRESS <br />D. <br />NEAREST CROSS STREET <br />E. DOES THE <br />5113 W. SARGENT RD. <br />l 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) <br />1 1 01 UNLEADED ( ) 02 REGULAR ( 103 PREMIUM (X) 04 DIESEL <br />CITY <br />IF YES CHECK APPROPRIATE BOX(ES): <br />1 06 OTHER <br />COUNTY <br />( ) 02 <br />ZIP <br />LODI <br />( ) 02 <br />SAN JOAQUIN <br />( 1 01 <br />95240 <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />5113 W. SARGENT RD. <br />LODI <br />CA <br />95240 <br />PHONE W/AREA CODE <br />TYPEOF BUSINESS <br />209-334-1316 <br />( ) 01 GASOLINE STATION (X) 02 OTHER <br />NURBEP OF CONTAINERS <br />RURAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />1 <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 />KAHLER, RINEY 209-334-1316 SAME - <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( ) 04 OTHER: <br />DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />CONTAINER NUMBER 1 <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: <br />C. <br />YEAR INSTALLED (X1 UNKNOWN <br />D. <br />CONTAINER CAPACITY: GALLONS (X) UNKNOWN <br />E. DOES THE <br />CONTAINER STORE: ( <br />l 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) <br />1 1 01 UNLEADED ( ) 02 REGULAR ( 103 PREMIUM (X) 04 DIESEL <br />01 YES ( ) 02 NO <br />f 1 05 WASTE OIL f <br />IF YES CHECK APPROPRIATE BOX(ES): <br />1 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) 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 f 103 LINED <br />D. (X) 01 CARBON STEEL [ ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS f 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br />( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE f ) 10 NON-METALLIC <br />( ) 12 UNKNOWN f ) 13 OTHER: <br />HSC04-070185 (10/18/85) PAC <br />- STATE ID NUMBER 00000048482001 <br />CONTAINER CONSTRUCTION <br />E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br />( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br />F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING f l 03 CATHODIC PROTECTION (X) 04 UNKNOWN f 1 05 NONE <br />f 1 06 TAR OR ASPHALT ( ) 09 OTHER: <br />VI PIPING <br />A. ABOVEGROUND PIPING: ( 101 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />B. UNDERGROUND PIPING: l ) 01 DOUBLE -WALLED PIPE ( ) 02 CONCRETE -LINED TRENCH ( ) 03 GRAVITY <br />(CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br />VII LEAK DETECTION <br />( ) 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br />( ) 06 GROUND WATER MONITORING WELLS f ) 07 PRESSURE TEST (X) 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 <br />STORED <br />PREVIOUSLY <br />STORED <br />DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br />( ) O1 <br />( ) 02 <br />( 1 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( 1 02 <br />( 1 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />( ) 01 <br />( ) 02 <br />( ) 03 <br />f ) 01 <br />( ) 02 <br />( 1 03 <br />( 1 01 <br />( 1 02 <br />( 1 03 <br />