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STATE ID NUMBER 00000046037001 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />(,O1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAME(CCRPOPATION,INDIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />DON S -.SRW MUNRO t l O1 FED ( ) 02 STATE ( 1 03 LOCAL <br />STREET ADDRESSt ,( ll STATE ZIP <br />LODI CA 95240 <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( l 04 <br />DEALER/FOREMAN.'SUPERVISOR <br />( ) GAUGE (X) INCHES ( <br />D & D MINI MART <br />CONTAINER NUMBER 1 <br />DON MUNRO <br />MANUFACTURER (IF APPROPRIATE)= PERKINS <br />STREET ADDRESS <br />YEAR MFG: 1977 <br />NEAREST CROSS STREET <br />YEAR INSTALLED 1977 ( l UNKNOWN <br />14971 N. HWY 88 <br />CONTAINER CAPACITY: <br />KETTLEMAN LANE <br />) UNKNOWN <br />CITY <br />CONTAINER STORE= ( <br />COUNTY <br />F. <br />ZIP <br />LODI <br />FUEL OR WASTE OIL ? (X) <br />PREMIUM ( ) 04 DIESEL <br />SAN JOAQUIN <br />IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 06 OTHER <br />95240 <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZiP <br />14971 N. HWY 88 <br />LODI <br />CA <br />95240 <br />PHONE W/AREA CODE <br />TYPE OF BUSINESS <br />209-369-1844 <br />(Xl 01 GASOLINE STATION ( ) 02 OTHER <br />NUMBER OF CONTAINERS <br />PUPAL AREAS ONLY : <br />TOWNSHIP <br />RANGE <br />SECTION <br />3 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: N.AME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />MUNRO, DON 209-369-1844 MUNRO, DON 209-33379E49 <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( l 04 <br />OTHER= <br />( ) GAUGE (X) INCHES ( <br />) CM ( ) UNKNOWN <br />CONTAINER NUMBER 1 <br />B. <br />MANUFACTURER (IF APPROPRIATE)= PERKINS <br />WELD. WORKS <br />YEAR MFG: 1977 <br />C. <br />YEAR INSTALLED 1977 ( l UNKNOWN <br />D. <br />CONTAINER CAPACITY: <br />9980 GALLONS ( <br />) UNKNOWN <br />JE. DOES THE <br />CONTAINER STORE= ( <br />) 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER <br />(X) 01 UNLEADED ( <br />STORE MOTOR VEHICLE <br />) 02 REGULAR ( ) 03 <br />FUEL OR WASTE OIL ? (X) <br />PREMIUM ( ) 04 DIESEL <br />01 YES ( ) 02 NO <br />( ) 05 WASTE OIL <br />IF YES CHECK APPROPRIATE BOX(ES): <br />( ) 06 OTHER <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY <br />CONTAINMENT: 1/4" <br />( ) GAUGE (X) INCHES ( <br />) CM ( ) UNKNOWN <br />B. <br />( ) 01 <br />VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) 01 <br />DOUBLE WALLED <br />(X) 02 SINGLE WALLED ( <br />) 03 LINED <br />D. <br />(X) 01 <br />( ) <br />( ) 12 <br />CARBON STEEL <br />06 ALUMINUM <br />UNKNOWN ( ) <br />( ) 02 STAINLESS STEEL ( <br />( ) 07 STEEL CLAD ( ) 08 <br />13 OTHER: <br />l 03 FIBERGLASS ( ) 04 <br />BRONZE ( ) 09 COMPOSITE <br />POLYVINYL CHLORIDE ( l 05 CONCRETE <br />( J 10 NON-METALLIC <br />HSC04-070185 (10/18/85) <br />PAGE 1 <br />