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STATE ID NUMBER 00000063304001 <br />APPLICATION FOR NDERGROUND STORAGE TANK <br />(X) 01 NEW PERMIT ( ) 05 RENEWED PERMIT 0# 07 TANK CLOSED (K) 09 DELETE FROM FILE (NO FEE) <br />P'T 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT t I US MIRUR CHIM (NO SURCHARG <br />I OWNER <br />NAME(CCRPORATION,INDIVIDUAL OR PUBLIC AGENCY) <br />(X) 01 TANK ( } 04 <br />PUBLIC AGENCY ONLY <br />GEORGE KISHIDA INC. <br />GEORGE KISHIDA INC. <br />( ) 01 FED ( ) 02 STATE ( ) 03 LOCAL <br />STREET ADDRESS <br />CITY <br />STATE <br />ZIP <br />172S`ACKERMAN DR. <br />LODI <br />CA <br />95240 <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( } 04 <br />OTHER: <br />DEALER/FOREMAN/SUPERVISOR <br />GEORGE KISHIDA INC. <br />B. <br />MANUFACTURER (IF APPROPRIATE): STK MFG. <br />GEORGE KISHIDA JR <br />STREET ADDRESS <br />��2� <br />CONTAINER CAPACITY: <br />NEAREST CROSS STREET <br />.1 Z Z� <br />Y-i�1trA <br />F. <br />•� - <br />CITY <br />01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />(X) 05 WASTE OIL ( ) 06 OTHER <br />(X) <br />( <br />( ) <br />COUNTY <br />ZIP <br />LODI <br />) 03 FIBERGLASS ( l 04 <br />BRONZE ( ) 09 COMPOSITE <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 10 NON-METALLIC <br />SAN JOAQUIN <br />95240 <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP <br />ZZ:3_&,e_5,;tZU4d6r?c <br />LODI <br />CA <br />95240 <br />PHONE W/AREA CODE <br />TYPE OF <br />BUSINESS <br />209-368-0603 <br />tX7 01 <br />GASOLINE STATION Ol 02 OTHER <br />NUMBER OF ONTAINEP.S <br />RURAL AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />x <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />)AYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />:Ee-%ZSWJZkz GEORGE JR. 209-368-0603 SAME 6 (-oco <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( } 04 <br />OTHER: <br />( ) GAUGE (X) INCHES ( <br />CONTAINER ,tL <br />B. <br />MANUFACTURER (IF APPROPRIATE): STK MFG. <br />YEAR MFG: wc, <br />YEAR INSTALLED -( ) UNKNOWN <br />D. <br />CONTAINER CAPACITY: <br />550 GALLONS ( ) UNKNOWN <br />JE. DOES THE <br />CONTAINER STORE: (12 01 WASTE LXX" 02 PRODUCT <br />F. <br />DOES THE CONTAINER <br />( ) 01 UNLEADED ( <br />STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) <br />) 02 REGULAR ( l 03 PREMIUM f*4 04 DIESEL <br />01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br />(X) 05 WASTE OIL ( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY <br />CONTAINMENT: 3/16 <br />( ) GAUGE (X) INCHES ( <br />) CM ( ) UNKNOWN <br />B. <br />f ) <br />01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) <br />01 <br />DOUBLE WALLED <br />(X) 02 SINGLE WALLED ( <br />) 03 LINED <br />D. <br />(X) <br />( <br />( ) <br />01 <br />) <br />12 <br />CARBON STEEL <br />06 ALUMINUM, <br />UNKNOWN ( ) <br />( 1 02 STAINLESS STEEL ( <br />t ) 07 STEEL CLAD ( l 08 <br />13 OTHER: <br />) 03 FIBERGLASS ( l 04 <br />BRONZE ( ) 09 COMPOSITE <br />POLYVINYL CHLORIDE ( ) 05 CONCRETE <br />( ) 10 NON-METALLIC <br />HSC04-070185 (10/18/85) PAGE 1 <br />