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• STATE ID NUMBER 00000065161004 <br /> ���� APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (�V 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED 1 ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 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 /> UCHAL-GAILCWICY 10, 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS ^D+ �� STATE z <br /> 420 W "*^'E"•" ' •"E CITY/y � � CA 931f0 <br /> II FACILITY <br /> FACILITY NAME DEALER/F REMAN/SUPC VISOR <br /> TOKAY SHELL �) <br /> STREET ADDRESS NEAREST CROSS/STREET <br /> 420 W. KETTLEMAN LANE l-Al <br /> CITY COUNTY 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 /> OAYS: 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 f ) 04 OTHER: CONTAINER NUMBER 2 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> 0. CONTAINER CAPACITY: 8000 GALLONS ( ) 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 ( 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 101 UNLEADED (X) 02 REGULAR ( 1 03 PREMIUM ( ) 04 DIESEL f ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( 1 03 LINED <br /> D. ( 1 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM 1 ) 07 STEEL CLAD 1 ) OB BRONZE f 1 09 COMPOSITE l ) 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> 4 HSC04-070185 (05/05/861 PAGE 1 <br />