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STATE ID NUMBER 00000065254002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 1 1 O1 NEW PERMIT ( ) 05 RENEWED PERMIT (X1 07 T ED i ) 09 DELETE FROM FILE (NO FEE) <br /> f 102 CONDITIONAL PERMIT t 1 06 AMENDED PERMIT ( ) MINOR CHA (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIOUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CHEROKEE MEMORIAL PARK. INC. ( ) 01 FED ( ) 02 STATE l 1 03 LOCAL <br /> STREET ADDRESS CITYSTATE ZIP <br /> HIGHWAY 99 AT HARNEY LANE LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> CHEROKEE MEMORIAL PARK, INC. J. CHARLES IRWIN <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 404� 23 BECKMAN RD. <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITY STATE ZIP <br /> P.O. BOX 1000 LODI CA 95241 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-334-%13 ( ) 01 GASOLINE STATION (X) 02 OTHER MEMORIAL PARK <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODENIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> IRWIN, J. CHARLES 209-334-%13 IRWIN. J. CHARLES 209-334-9222 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 2 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS (X) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 HASTE (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 /> ( ) <br /> 01 UNLEADED l ) 02 REGULAR 1 ) 03 PREMIUM (X) 04 DIESEL f ) 05 WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES l ) CM (X) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f 1 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. f 1 01 DOUBLE WALLED 1 ) 02 SINGLE WALLED ( ) 03 LINED <br /> D. f l 01 CARBON STEEL ( 1 02 STAINLESS STEEL f 103 FIBERGLASS ( O 04 POLYVINYL CHLORIDE l 1 05 CONCRETE <br /> ( ) 06 ALUMINUM l ) 07 STEEL CLAD f ] 08 BRONZE 1 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> (XI 12UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (05/05/86) PAGE 1 <br />