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• STATE ID NUMBER 00000034920001 <br /> APPLICATION FOR PERMIT TO OP TE UNDERGROUND STORAGE TANK <br /> f ) 01 NEW PERMIT ( 1 05 RENEWED PERMIT ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT 8 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CITY OF LODI 0 f ) 01--FED f ) 02 STATE (_f 03 LOCAL <br /> STREET ADDRESS CITY \ .STATE ZIP <br /> 221 W. PINE ST LODI 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> PARKS & RECREATION JUAN MENDEZ), 09OLrki.9 5m+erlll5ar- <br /> STREET ADDPESS NEAREST CROSS STREET <br /> 125 N. STOCKTON ST LOCUST ST <br /> CITY <br /> COUNTY IIP <br /> LODI SAN JOAgUIN 95240 <br /> MAILING ADDRESS CITY <br /> STATE ZIP <br /> 221 W. PINE ST LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-334-5634 ( 1 01 GASOLINE STATION (X) 02 OTHER VEHICLE MAINT <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 CODENIGHTS: NAME)LAST NAME FIRST) AND PHONE W/AREA CODE <br /> LODI FIRE DEPT. 209-369-3531 SAME ?d -AOL 3 S <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 125-1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1940 C. YEAR INSTALLED 1940 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 250 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: (X) 01 WASTE ( ) 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 ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL (X) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1/4 f ) GAUGE (X) INCHES ( ) CM ( ) 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 ( i 03 LINED <br /> 0. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> f ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE f ) 10 NON-METALLIC <br /> ( ) 12 U14KNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) <br /> PAGE 1 <br />