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4 • <br /> STATE ID NUMBER 00000062578001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> f 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE, t FEE) <br /> 2 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CHEVRON U.S.A. INC. ( ) 01 FED ( ) 02 STATE t ) 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 575 MARKET SAN FRANCISCO CA 94105 <br /> II FACILITY y p <br /> FACILITY NAME d rO A- /lfr3- DEALER/FOREMAN/SUPERVISOR <br /> 94--tr 40® PAIGE, KENNETH W <br /> 41 <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 236 N. HAM LANE LOCKEFORD <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN. 95240 <br /> MAILING ADDPESS CITY STATE ZIP <br /> 236 N. HAM LANE LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-334-2241 (X) 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER, OF CONTAINERS PUPAL AREAS ONL�TOWNSHIP RANGE SECTION <br /> 4 <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 /> MAINTENANCE DISPATCH 415-877-0244 - - <br /> COMPLETE THE FOLLOWING Ofit A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER X Z <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1969 C. YEAR INSTALLED 1%9 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 10040 GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? POrt 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> (kI 01;UNLEADED ( ) 02 REGULAR A*On 3 IUM ( ) 04 DIESEL ( ) ,05 WASTE OIL ( l 06 OTHER' <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS Of PRIMARY CONTAINMENT: 0000250 ( ) GAUGE f 1 INCHES ( ) CM ( ) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (XI 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED f ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS t l 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM f 1 07 STEEL CLAD ( 108 BRONZE ( l 09 COMPOSITE ( T 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> i � <br />