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STATE ID NUMBER 00000061703004 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (;j;;�.01 NEW PERMIT f ) 05 RENEWED PERMIT f 07 TANK CLOSED (yyyy� 09 DELETE FROM FILE lN0 FEE1 <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 08 MINOR CHANGE (NO SURCHARGE <br /> I OWNER <br /> NAME(COPPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CHEVRON U.S.A. INC. ( ) 01 FED ( ) 02 STATEf 1 03 LOCAL <br /> STREET ADDRESS CITY STATE IIP <br /> 575 MARKET SAN FRANCISCO CA 94105 <br /> II FACILITY <br /> FACILITY N^AM/IE_ � DEALER/FOREMAN/SUPERVISOR <br /> C,✓�("C) QQ V1"D KUBACH, KENT W �PQ,rq�-p✓� <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 101 N. CHEROKEE LANE ELM <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITYSTATE ZIP <br /> 101 N. CHEROKEE LANE LODI CA 95240 <br /> PHONE W/A P.EA cone TYRE OF BUSINESS <br /> 209-334-9361 (X) 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER CF CONTAINER¢ RURAL AREAS ONLY 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 ON A SEPARATE FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 4 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1966C. YEAR INSTALLED 1%6 ( 1 UNKNOWN <br /> D. CONTAINER CAPACITY: 550 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: (X) 01 WASTE f l 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> ( ) 01 UNLEADED f ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL D(f 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 0000100 f ) GAUGE 1 ) INCHES ( ) CM 1 ) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. [ 1 01 DOUBLE WALLED (X) 02 SINGLE WALLED t ) 03 LINED <br /> 0. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM f ] 07 STEEL CLAD f ) 08 BRONZE ( ) 09 COMPOSITE f ) 10 NON-METALLIC <br /> ( l 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />