Laserfiche WebLink
i <br /> � STATE ID NUMBER 00000034934001 <br /> APPLICATION FOR PERMIT TO <br /> ( ) 01 NEW PERMIT AT UfJDERGROUND STORAGE TANK <br /> ( 1 02 CONDITIONAL PERMIT ( ) 05 RENEWED PERMIT <br /> ( ) 06 AMENDED PERMIT ) 0 TANK LOSED MINOR f ) 09 DELETE FROM FILE (NO FEE) <br /> OWNER CHANGE (NO SURCHARGE) <br /> I <br /> NAME(CORPORATION,INDIVIOUAL OR PUBLIC AGENCY) <br /> CITY OF LODI <br /> PUBLIC AGENCY ONLY <br /> STREET ADDRESS ( ) )I FED ( 1 02 STATE <br /> 221 W. PINE ST. ) 03 LOCAL <br /> carr <br /> LODI jSTATE lZIP <br /> II FACILITY CA 95240 <br /> FACILITY NAME <br /> ( DEALER/FOREMAN/SUPERV SOR <br /> Ca LSP 1-a�Qi- We ll�-yF�I/l <br /> STREET ADDRESS -- FRAN E. FORKAS/ ) <br /> 114 N. MAIN ST. NEAREST CROSS STREET <br /> CITY LOCUST ST. <br /> LODI COUNTY <br /> MAILING ADDRESS SAN JOAQUIN ZIP <br /> 95240 <br /> 1331 SO. HAM LN. CITY <br /> Zip <br /> PHONE W/AREA CODE LODI ISTATE <br /> CA 95240 <br /> 209-333-6740 TYPE of BusxNEss <br /> ( 1 <br /> NUMBER OF CONTAINERS 01 GASOLINE STATION (X) 02 OTHER WATER WELL <br />' <br /> 1 RURAL AREAS ONLY TOWNSHIP <br /> RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> UTILITY OPERATORS 209-368-5735 <br /> UTILITY OPERATORS 209-368-573573 5 <br /> ------------ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: <br /> CONTAINER NUMBER 4 <br /> B. MANUFACTURER IIF APPROPRIATE): <br /> YEAR MFG: C. YEAR INSTALLED <br /> (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 350 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) O1 WASTE (Xl 02 PRODUCT <br /> R. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL O( )E05 WASTE NO <br /> fI) 06 YES <br /> OTHERK APPROPRIATE BOX(ES): <br /> CONTAINER CONSTRUCTION <br />. THICKNESS OF PRIMARY CONTAINMENT: 1/4 ( 1 GAUGE (X) INCHES ( ) CM ( ) UNKNOWN <br /> ( 7 <br /> 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( l 03 LINED <br /> (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) OS CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( 1 12 UNKNOWN ( ) 13 OTHER: <br /> 04-070185 (10/18/85) <br /> PAGE 1 <br />