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STATE ID NUMBER 00000010404001 <br />APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br />LObyl NEW PERMIT ( ) 05 RENEWED PERMIT f ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br />r-) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br />I OWNER <br />NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br />PAR", Elle ( ) 01 FED f ) 02 STATE f 1 03 LDCAL <br />STREET ADDRESS CITY STATE ZIP <br />12145 N. DE VRIES RD LDDI CA 95240 <br />II FACILITY <br />FACILITY NAME <br />(X) 01 TANK ( ) 04 OTHER: <br />CONTAINMENT: ( <br />DEALS /FOREMAN/SUPERVISOR <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />rR <br />C. <br />L <br />0. <br />STREET ADDRESS <br />E. DOES THE CONTAINER STORE: ( <br />1 01 WASTE (X) 02 PRODUCT <br />NEAREST CROSS STREET <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO <br />f 101 UNLEADED ( ) 02 REGULAR f ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL <br />12145 N. DE VRIES RD <br />D. <br />(X) <br />( ) <br />ARMSTRONG RD <br />f 1 02 STAINLESS STEEL f 103 FIBERGLASS l ) 04 <br />f 1 07 STEEL CLAD l ] 08 BRONZE f 1 09 COMPOSITE <br />13 OTHER: <br />CITY <br />COUNTY <br />ZIP <br />LODI <br />SAN JOAQUIN <br />95240 <br />MAILING ADDRESS <br />CITY <br />STATE, <br />ZIP <br />12145 N. DE VRIES RD <br />LODI <br />CA <br />95240 <br />PHONE W/AREA CODE <br />TYPE OF BUSINESS <br />209-368-5889 <br />AH 01 GASOLINE STATION (X1 02 OTHER ULFaIZ.T <br />NUMBER OF CONTAINERS <br />RURAL <br />AREAS ONLY <br />TOWNSHIP <br />RANGE <br />SECTION <br />1 <br />III 24 HOUR EMERGENCY CONTACT PERSON <br />DAYS: NAMEILAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br />TROGLIN, ALBERT 209-368-5889 TROGLIN, ALBERT 209-464-4422 <br />COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br />IV DESCRIPTION <br />A. <br />(X) 01 TANK ( ) 04 OTHER: <br />CONTAINMENT: ( <br />CONTAINER NUMBER 1 <br />B. <br />MANUFACTURER (IF APPROPRIATE): <br />YEAR MFG: 1980 <br />C. <br />YEAR INSTALLED 1983 ( 1 UNKNOWN <br />0. <br />CONTAINER CAPACITY: 10000 GALLONS f ) UNKNOWN <br />E. DOES THE CONTAINER STORE: ( <br />1 01 WASTE (X) 02 PRODUCT <br />F. <br />DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO <br />f 101 UNLEADED ( ) 02 REGULAR f ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL <br />IF YES CHECK APPROPRIATE BOX(ES): <br />(X) 06 OTHER AVIATION FUEL <br />V CONTAINER CONSTRUCTION <br />A. <br />THICKNESS OF PRIMARY <br />CONTAINMENT: ( <br />) GAUGE ( ) INCHES ( <br />) CM (X1 UNKNOWN <br />B. <br />( ) <br />01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) <br />(X) 02 NON -VAULTED ( <br />) 03 UNKNOWN <br />C. <br />( ) <br />01 DOUBLE WALLED <br />(X) 02 SINGLE WALLED ( ) <br />03 LINED <br />D. <br />(X) <br />( ) <br />01 CARBON STEEL <br />( ) 06 ALUMINUM <br />12 UNKNOWN ( ) <br />f 1 02 STAINLESS STEEL f 103 FIBERGLASS l ) 04 <br />f 1 07 STEEL CLAD l ] 08 BRONZE f 1 09 COMPOSITE <br />13 OTHER: <br />POLYVINYL CHLORIDE f ) 05 CONCRETE <br />f ) 10 NON-METALLIC <br />HSC04-070185 (10/18/85) <br />PAGE 1 <br />