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• &NA 1 2,--f � STATE ID NUMBER 00000045147001 <br /> APPLICATION FOR PERMIT TO OPE ATE UNDERGROUND STORAGE TANK <br /> ( 1 <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT 07 TANK CLOSED ( ] 09 DELETE FROM FILE (NO FEE) <br /> t 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) E (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPOP.ATION,INOIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> JAMES F. CULBERTSON ( ) 01 FED f 1. 02 STATE ( l 03 LOCAL <br /> STREET ADDRESSCITY STATE ZIP <br /> 641 N. PACIFIC AVE. LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> JAMES F. CULBERTSON OWNER <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 419 E. TAYLOR ROAD LOWER SACTO RD. <br /> CITY COUNTY ZIP <br /> LOOI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 641 N. PACIFIC AVE. LORI CA 95240 <br /> PHONE W/APEA CODE TYPE OF BUSINESS <br /> 209-369-2423 ( ) 01 GASOLINE STATION (X) 02 OTHER CONTRACTOR <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/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> JAMES F. CULBERTSON 209-369-2423 JAMES F. CULBERTSON 209-369-2423 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 300 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: f ) 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 (X) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL l ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED t l 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL t 1 03 FIBERGLASS t ) 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 /> H5C04-070185 (10/18/85) PAGE 1 <br />