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STATE ID NUMBER 00000040905002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> • ( ) <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMITANK CLOSED 09 DELETE FROM FILE (NO FEE) <br /> 08 <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT /( 1MINOR CHANGE (NO SURCHARG <br /> I OWNER <br /> NAME(CORPOPAT:ON.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> Y o-fi ef- ( ) 01 FED ( ) 02 STATE ( l 03 LOCAL <br /> STREET ADDRESS A {� CITY STATE ZIP <br /> STPEETW SS LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME r DEALER/FOREMAN/SUPERVISOR <br /> So m's o C�inLc $B"%+*ER C carK <br /> STREET ADDRESS NEAREST CROS TREET <br /> VICTOR RD. <br /> TY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS 1� � �/� CITYSTATE ZIP <br /> 1;A68�M"RN1`-99' 6 31f7 C Q,AJppq Ylt�• LODI CA 95240 <br /> PHONE W/AREA CCDE TYPE OF BUSINESS <br /> 01 GASOLINE STATION (X) 02 OTHER _FFWC <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> CA'S: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> KELLER DON 209-369-1887 - <br /> COMPLETE THE FOLLOWING ON •A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBERx/ <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: I C. YEAR INSTALLED (X) UNKNOWN <br /> 0. CONTAINER CAPACITY: 500 GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: (X) 01 WASTE ( 1 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 f ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL (X) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE f ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM (X) 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE ( P 10 NON-METALLIC <br /> ( ) 12 UNKNOWN i ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> 0 is <br />