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STATE ID NUMBER 00000034932001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( 7 01 NEW PERMIT ( ) 05 RENEWED PERMIT -1'1'08 <br /> Od P7 TANK CLOSED (+�El 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT T) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CITY OF LODI ( ) 01 FED f l 02 STATE Q:f 03 LOCAL <br /> STREET ADDRESS CITYSTATE IF <br /> 221 W. PINE ST. LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAM! / l DEAL EP/FOP EMAN/SUPERVISOR 1 <br /> FRAN E. FORKAS, Sµ r(h'ft[14�A� <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 236 1/2 CHERRY VINE ST. <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 1331 SO. HAM LN. LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 2 O2zi 3 2-k 1 GASOLINE STATION (X) 02 OTHER WATER WELL <br /> NUMBER OF CON RURAL AREAS ONIY TOWNSHIP RANGE SECTION <br /> 1 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME)LAST NAME FIRST) AND PHONE W/AREA COO! NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA COD! <br /> UTILITY OPERATOR 209-368-5735 UTILITY OPERATORS 204-368-5735 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 6 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 350 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 ? (X) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> f ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL ( ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1/4 f ) GAUGE (X) INCHES ( ) CM ( ) UNKNOWN <br /> B. f ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> D. (X) 01 CARBON STEEL [ 1 02 STAINLESS STEEL [ 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE f 1 09 COMPOSITE ( ) 30 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/65) PAGE 1 <br /> 4laz w <br /> i <br />