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40 m <br /> -l` STATE ID NUMBER 00000034920002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT [ ) 05 RENEWED PERMITf 1 07 TANK CLOSED <br /> ( NGE 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHA ( 10 SURCHARGE)) 09 DELETE FROM FILE (NO FEET <br /> I OWNER <br /> NAME(CORPOPATION,ZNOIVIDUAL OR PUBLIC AGENCY) <br /> CITY OF LODI PUBLIC AGENCY ONLY <br /> ( 7 <br /> 01 FED [ 1 02 STATE .2L 03 LOCAL <br /> STREET AODPESS <br /> 221 W. PINE ST CITY STATE IIp <br /> LOOI CA 95240 <br /> II FACILITY <br /> ffN. STOCKTON <br /> TION DEALER/FOREMAN/SUPERVISOR <br /> JUAN MENDEZJ 9cx S a.v o50 <br /> NEAREST CROSS STREET <br /> ST LOCUST ST <br /> COUNTY IP <br /> SAN JOA©UIN 295240 <br /> MAILING ADDRESS CITY STATE IIP <br /> 221 W. PINE ST LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-334-5634 ( ) 01 GASOLINE STATION (X) 02 OTHER VEHICLE MAINT <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE <br /> 3 SECTION <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 /> LODI FIRE DEPT. 209-369-3531 SAME <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: CONTAINER�NUMBER5-2 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1940 C. YEAR INSTALLED 1940 ( ) UNKNOWN <br /> O. CONTAINER CAPACITY: 1000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( 1 01 WASTE (X) 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 (X) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1/4 ( ) 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 ( ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( l 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) <br /> PAGE 1 <br />