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• STATE ID NUMBER 00000009092001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED f 1 09 DELETE FROM FILE (NO FEE) <br /> f ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CCRPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> LODI IRON WORKS. INC. ( l 01 FED ( ) 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 1029 S. SCHOOL STREET <br /> LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME OrR/FOREMAN/SUPERVISOR <br /> LODI IRON WORKS. INC. <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1029 S. SCHOOL STREET PARK <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS <br /> CITY STATE ZIP <br /> P.O. BOX LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-368-5395 f 1 01 GASOLINE STATION (X) 02 OTHER FOUNDRY <br /> NUMBER OFCONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> l/ I <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 /> VAN STEENBERGE, KEVIN 209-368-5395 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 t 1 04 OTHER: CONTAINER NUMBER A3 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 500 GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE fX) 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 /> (X) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( 1 04 DIESEL ( 1 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 12 (X) GAUGES 1 1 INCHES f ) CM l ) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X1 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. f 101 DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ] 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />