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STATE ID NUMBER 00000011269001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> l�l <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( 1 09 DELETE FROM FILE (NO FEE', <br /> ( i 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> NOSUUO. KKIIS!H;IIDDAA ( ) 01 FED ( ) 02 STATE l 1 03 LOCAL <br /> STREET w9;;Rt, < <br /> �j n ♦ CITY STATE ZIP <br /> ODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> NOBUO KISHIDA OWNER <br /> $TPEET ADDRESS NEAREST CROSS STREET <br /> 177 SO KELLY ST. LODI AVE. <br /> CITYCOUNTY <br /> Zip <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESSCITY STATE ZIP <br /> 1�G�-AR• /�,-. /& fr. l t�F,- LODI CA 95240 <br /> PHONE W/AREA CODE v 4: TYPE OF BUSINESS <br /> 209-334-3030 ( ) 01 GASOLINE STATION (X) 02 OTHER TRUCKING <br /> NVMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANCE SECTION <br /> 2 <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 /> KISHIDA, HOSUO 209-334-3030 KISHIDA, HOSUO 209-369-2140 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1975 C. YEAR INSTALLED 1975 f ] UNKNOWN <br /> D. CONTAINER CAPACITY: 10000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: f ) 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 /> l 1 <br /> 01 UNLEADED ( 1 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" ( ) GAUGE (X) INCHES ( ) CM f ) UNKNOWN <br /> B. ( ) Ol VAULTED (LOCATED IN AN UNDERGROUND VAULT) (XJ 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( ] 02 STAINLESS STEEL f 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( 1 06 ALUMINUM ( 1 07 STEEL CLAD ( 1 08 BRONZE f ) 09 COMPOSITE f ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> llpl `r <br />