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STATE ID NUMBER 00000034931001 <br /> APPLICATION FOR P RATE UNDERGROUND STORAGE TANK <br /> ( 1 01 NEW PERMIT f ) 05 RENEWED PERMIT 0TANK CLOSE �1 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT 08 NGE (NO SURCHARG <br /> I OWNER <br /> NAME(C OPPOP.ATION,IND IVZDUAL OR PUBLIC AGENCY) PUBLIC A�( ) <br /> CITY OF LODI ( ) 01 FSTATE 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 221 W. PINE ST. LODI CA 95240 <br /> II FACILITY <br /> fACILIIV NAM(E� DEALE RF OREMAN/SUPERVISOR ,( <br /> FRAN E. FORKAS, su l'(h�BhQe�T <br /> STREET AGGRESS NEAREST CROSS STREET <br /> 1408 S. STOCKTON ST. <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS <br /> CITY STATE ZIP <br /> 1331 SO. HAM LN. LODI CA 95240 <br /> 0 <br /> PHONE W/AP.EA CODE TYPE OF BUSINESS <br /> 209-333-6740 ( ) 01 GASOLINE STATION (X) 02 OTHER WATER WELL <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 1 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AP.EA CODE NI GNTS: NAME(LAST NAME FIRST) ANDDD PHONE W/AREA CODE <br /> UTILITY OPERATORS g68-6773-6UTILITY OPERATORSeLV O- 3.5-- <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 8 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 350 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES); <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL f 1 05 WASTE OIL ( ] 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1/4 ( 1 GAUGE (X) INCHES ( ) CM ( ) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 1 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> 0 <br />