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• STATE ID NUMBER 00000065161003 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ! 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( U 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> t ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT l ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INDIVIDUAL OR PURL C pAGENC ) PUBLIC AGENCY ONLY <br /> MrrHAI /J t ) 01 FED ( ) 02 STATE f ) 03 LOCAL <br /> STREET ADDRESS - CITYSTATE ZIP <br /> 42.0-i1r-14E�i6ipAN-kANE Po,X' 71LOK ICA 95M <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> TOKAY SHELL <br /> STREET ADDRESS NEAJHEeT"CWCV"fffrT <br /> 420 N. KETTLEMAN LANE <br /> CITY ,....a.... ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITYSTATE ZIP <br /> 420 W. KETTLEMAN LANE LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-334-0568 (X) 01 GASOLINE STATION 1 ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 4 <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 /> MIKE GALLOWAY 209-334-0568 GALLOWAY, MIKE 209-578-0169 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 3 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> O. CONTAINER CAPACITY: 5000 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 f ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) <br /> 01 UNLEADED l ) 02 REGULAR (X) 03 PREMIUM ( ) 04 DIESEL f 1 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (X) 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. ( 1 01 CARBON STEEL ( ) 02 STAINLESS STEEL [ ) 03 FIBERGLASS 1 ) 04 POLYVINYL CHLORIDE f ) 05 CONCRETE <br /> t ) 06 ALUMINUM ( 1 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE 1 ) 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (05/05/86) PAGE 1 <br />