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APPLICATION FOR PERMIT TO 0 ► STATE ID NUMBER 0000000959000, <br /> 1 NEW PERMIT ,P 'TIE "I1PIDERGR <br /> 1 02 CONDITIONAL PERMIT f 1 05 RENEWED PERMIT y� STORAGE TANK <br /> ( ] 06 AMENDED PERMIT (�^j p08MMII CCRAN�E (NO SURCHARGE)] 09 DELETE FROM FILE IND FEE) <br /> I OWNER <br /> "HUST <br /> TION.XNDIVIDUAL OR PUBLIC AGlNCYI <br /> NS INCPUBLIC AGENCY ONLY <br /> S 01 FED ( ) 02 STATE ( ) 03 LOCS7 <br /> CITY <br /> LODI STATE ZIP <br /> CA <br /> II FACILITY 95240 <br /> [GG <br /> ITY NAM! <br /> UST & SONS INC DEALER/FOREMAN/SUPERV SORT ADDRESS A s SCHOOL ST NEARES CROSS STREET <br /> LOCUST & ELM <br /> COUNTY ZIP <br /> SAN JOAQUIN 95240 <br /> MAILING ADDRESS <br /> 116 N SCHOOL ST CITY <br /> LODI STATE ZIP <br /> CA 95240 <br /> PHONE W/AREA CODE q � C TYPE OF BUSINESS <br /> 209-36G.y4rH3- 3 356 (X) 01 GASOLINE STATION f 1 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE <br /> 1 LOD SCCTION <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 /> ROY S MUST 209= 4-x..._333-33.� ROY S MUST 209- -- X34 _ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER R1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1974 ( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 350 GALLONS f ) UNKNOWN E. DOES THE CONTAINER STORE: f 1 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES 1 1 02 NO IF YES CHECK APPROPRIATE BOX(ES1: <br /> (X) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL f ) 05 WASTE OIL ( ) 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. ( ) 001 DOUBLE WALLED 2 SINGLE WALLED ( ) 03 LINED <br /> D. yy-v1 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 7 05 CONCRETE <br /> 06 ALUMINUM ( 7 07 STEEL CLAD ( ] 08 BRONZE ( 1 09 COMPOSITE [ 1 10 HON-METALLIC <br /> 1 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> STATE ID NUMBER 00000009590001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 7 02 VINYL WRAPPING ( 1 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(E5) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> S. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (XI 05 SUCTION ( l 06 UNKNOWN f ) 07 NONE <br /> VII LEAK DETECTION <br /> f 1 01 VISUAL ( ) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT <br /> [ ) 06 GROUND WATER MONITORING WELLS [ 1 07 PRESSURE TEST (X) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKEO YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 1 ) Ol ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f 1 Ol ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( 1 02 ( l 03 <br /> ( ) 01 f ) 02 ( 1 03 <br /> f ) <br /> 01 ( ) 02 ( 103 <br /> ( 1 01 ( ) 02 ( ) 03 <br />