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�ScoL <br /> STATE IO NUMBER 0000000925001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> C ) 01 NEW PERMIT l l 05 RENEWED PERMIT (X 0 ( ) 09 DELETE FROM FILE (NO FEE) <br /> MSNI <br /> ill 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 1 08 RR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COP.PORATION,INDIVIDUAL OR PUBLIC AGENCY) _ ® PUBLIC AGENCY ONLY <br /> G ( ) 01 FED f ) 02 STATE f ) 03 LOCAL <br /> STREET ADDRESS CITYSTATE ZIP <br /> 240 H. CHEROKEE LN. LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOR MAN/SUPE VISOR <br /> LODI TIRE SERV19 f <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 3ll0rN.-CWEREKEE'LN 2-so 1I) ifkeso Kae, LA LOCKEFORD ST. <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRISS CITY STATE ZIP <br /> `il" ^ ^^"r�`rcn- yQ LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-369-1985 ( 1 01 GASOLINE STATION (X) 02 OTHER TIRE-SHOP <br /> NUMBER OF CONTAINERS RURAL APEAS ONLY TOWNSHIP RANGE SECTION <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 /> PARSON ED Kc 204.3]4—BRE? ,.,� SAME 209-10?-l"5 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. 1X1 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 3V 3 <br /> B. MANUFACTURER (IF APPROPRIATE): PERKINS WELDING YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 100 GALLONS ( l 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 (X) 02 REGULAR ( ) 03 PREMIUM f ) 04 DIESEL 1 ) 05 WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 10 (X) GAUGE ( ) 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 ( ) 03 LINED <br /> 0. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ] 05 CONCRETE <br /> f ) 06 ALUMINUM ( l 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> [ 1 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> >♦r ♦r <br />