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• } • s3ATE ID NUMBER 00000065161001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ;}(P'O1 NEW PERMIT ( ) 05 RENEWED PERMIT / 07 TANK CLOSED -r 09 DELETE FROM FILE (NO FEE) <br /> , 1 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 /> MSCMtFt-BAttMM1' �� a / ( ) 01 FED f ) 02 STATE ( ) 00`3y LOCAL <br /> STREET ADDRESS CINE (.?.[!.tl� STATE ZIP r J� <br /> 420 WW HPTT NE o 7�Z CA 91240 <br /> II FACILITY <br /> FACILITY NAME DEALER FDR):MAN/SUPERVISOR <br /> TOKAY SHELL ��7�L..Lizt.' <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 420 W. KETTLEMAN LANE LA-) <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITY STATE 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 1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 10000 GALLONS ( l UNKNOWN I 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 t ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> (X) 01 UNLEADED l ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL t ) OS WASTE OIL t ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( l 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. l 1 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( ) 03 LINED <br /> D. 1 ) 01 CARBON STEEL [ 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> f ) 06 ALUMINUM 1 ) 07 STEEL CLAD ( l 08 BRONZE t 1 09 COMPOSITE ( 1 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (05/05/86) PAGE 1 <br />