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STATE ID NUMBER 00000018493001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) 01 NEW PERMIT ( ) 05 RENEWED PERMIT f ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT f ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPOBATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CLARENCE C. SEVERSON ( ) 01 FED ( ) 02 STATE f ) 03 LOCAL <br /> STREET ADDPESS CITY STATE ZIP <br /> 11374 N MICKE GROVE RD. LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> CLARENCE C. SEVERSON <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 11374 N MICKE GROVE RD. <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 11374 N MICKE GROVE RD. LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-334-2938 ( ) 01 GASOLINE STATION (X) 02 OTHER HOME USE <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 2 <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 /> SAME 209-334-2938 SAME 209-334-2938 <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: 500 GALLONS ( ) UNKNOWN E. ROES 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 /> f ) <br /> 01 UNLEADED (X) 02 REGULAR f ) 03 PREMIUM ( ) 04 DIESEL ( 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> 0 <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( 1 INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED f ) 03 LINED <br /> D. ( ) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS f l 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM (X) 07 STEEL CLAD f 1 08 BRONZE ( 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> � ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> i • <br />