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s <br /> STATE ID NUMBER 00000012822002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT f 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INOIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> KENNETH 0. DYER ( ) 01 FED t ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE 9524IIP <br /> 13671 E. PINTO LN. LODI CA 0 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> KEN'S MOBIL KENNETH 0. DYER <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 126 W. TURNER RD. CHURCH <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 126 W. TURNER RD. LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-334-3301 (X) 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 4 <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 /> DYER, KENNETH D. <br /> 209-334-3301 DYER, KENNETH 0. 209-727-5589 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (XI 01 TANK ( 1 04 OTHER: CONTAINER NUMBER 01 <br /> B. MANUFACTURER (IF APPROPRIATE): UNKNOWN YEAR MFG: C. YEAR INSTALLED 1963 ( ] UNKNOWN <br /> 0. CONTAINER CAPACITY: 4000 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 ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( 7 02 REGULAR (X) 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL ( l 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) ) 02 NON—VAULTED tl�l 03 UNKNOWN <br /> C. ( i 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( 1 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE f 1 05 CONCRETE <br /> t ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON—METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />