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STATE ID NUMBER 00000013223001 <br /> APPLICATION FOR PERMIT TOZ <br /> TE UNDERGROUND STORAGE TANK <br /> fydl 01 NEW PERMIT ( ) 05 RENEWED PERMIT TANK CLOSED +%��L"z DELETE FROM FILE (NO FEE) <br /> f 1 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT l 08 MINOR CHANGE lN0 SURCHARGE)' <br /> I OWNER <br /> NAME(CORPOFATION,INDIVIOUAL OR PUBLIC AOENCY) PUBLIC AGENCY ONLY <br /> LODI FUNERAL HOME, INC. f ) 01 FED ( ) 02 STATE [ ) 03 LOCAL <br /> STREET ADDRESS CITY STATE IIP <br /> 725 SOUTH FAIRMONT AVENUE LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> LODI FUNERAL HOME LEONARD G. MESSER, MGR. <br /> STREET ADOR!SS NEAREST CROSS STREET <br /> 725 SOUTH FAIRMONT AVENUE <br /> CITY COUNTY <br /> zxv <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDPESS CITY STATE ZIP <br /> SAME AS ABOVE LOBI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-369-3564 ( ) 01 GASOLINE STATION (X1 02 OTHER FUNERAL HOME <br /> NUMBER. OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> I N/A <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAMC(lAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> LEONARD G. MESSER 209-369-3564 SAME - - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER ONE <br /> B. MANUFACTURER (IF APPROPRIATE): UNK YEAR MFG: C. YEAR INSTALLED 1967 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 300 GALLONS f 1 UNKNOWN E. DOES THE CONTAINER STORE: ( l 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES f l 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> 00 01 UNLEADED f ) 02 REGULAR ( 1 03 PREMIUM ( ) 04 DIESEL f ] 05 WASTE OIL f ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. ,THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( l INCHES ( 1 CM (X) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED 1 <br /> 02 SINGLE WALLED f ) 03 LINED <br /> D. (X) 01 CARBON STEEL f ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS [ 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> I ) 06 ALUMINUM ( l 07 STEEL CLAD f l 08 BRONZE f 1 09 COMPOSITE ( ) 10 NON-METALLIC <br /> l ] 12 UNKNOWN ( ) 13 OTHER: <br /> MSC04-070185 (10/18/85) PAGE 1 <br /> I <br /> d. �„1 <br />