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v° <br /> STATE ID NUMBER 0000000 OD) <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> E( <br /> (� I 01 NEW PERMIT ( 1 05 RENEWED PERMIT V() 07 T K CSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( 1 0 MING LOANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC A ENCY) PUBLIC AGENCY ONLY <br /> 'Q&` -`f^E� t C( ( ) Ol FED [ ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 240 N. CHEROKEE LN. LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> LODI TIRE SERV 4 <br /> ( <br /> STREET ADDRESS kra /'�� NEAREST CR095 STREET <br /> ASO N• C{1.Cf0 r LOCKEFORD ST. <br /> CITY COUNTY <br /> 2IP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITYSTATE ZIP <br /> gi <br /> 4E ml y0 LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-369-1985 ( ) 01 GASOLINE STATION (X) 02 OTHER TIRE-SHOP <br /> NUMBER OF ONTAINERS RURAL AREAS 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/ Kl u- 209-434-B+w lj j_& SAME 209-369-'Y99rr'73T,v=Q62,5­ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: CONTAINER NUMBER 2 <br /> B. MANUFACTURER (IF APPROPRI'TATTEE): PERKINS WELDING YEAR MFG: iC. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN E. GOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES l ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f ) <br /> 01 UNLEADED (X) 02 REGULAR f 7 03 PREMIUM ( 1 04 DIESEL f ) OS WASTE OIL [ ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 10 (X) GAUGE f 1 INCHES ( ) CM 1 ) 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 l 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( 1 06 ALUMINUM ( ) 07 STEEL CLAD ( ] 08 BRONZE l 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />