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M • STATE ID NUMBER 00000034933001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 7 <br /> 01 NEW PERMIT f ) 05 RENEWED PERMIT J .-47 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE) <br /> f ) 02 CONDITIONAL PERMIT f ) 06 AMENDED PERMIT l ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CITY OF LODI ( ) 01 FED ( ) 02 STATE f 1 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 221 W. PINE ST. LODI CA 95240 <br /> II FACILITY <br /> FACILITY NA i �(� ��; <br /> vie- <br /> DEALERFOREMAN/SUPERVISOR <br /> U(/ <br /> �9CFRAN E. FORKAS <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 401 N. MILLS AVE COLETTE ST. <br /> CITY COUNTY ZIP <br /> LODI - SAN JOAQUIN 95240 <br /> MAILING ADDRESSCITY STATE ZIP <br /> 1331 S. HAM LN. LOOI CA 95240. <br /> PHONE W/AR-EA CODE TYPE OF BUSINESS <br /> 209-333-6740 ( 7 01 GASOLINE STATION (X) 02 OTHER WATER WELL <br /> NUMBER OF CONTA2 HERS 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 /> UTILITY OPERATOR ,y[ -f(og S� . CITY OPERATOR 209-368-5735 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 5 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 350 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 ( 7 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED f ) 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL ( l 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1/4 f 1 GAUGE (X) INCHES ( ) CM f ) 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 ( 1 03 LINED <br /> 0. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM f ) 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> C ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />