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• • STATE ID NUMBER 00000020285002 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> (A) 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,INOIVIDUUA}LL ORn PUBLICp AGENCY) 1 7 PUBLIC AGENCY ONLY <br /> /�D-T¢•(.�C.U/ >�,(.{ F./n,Ci• f ) 01 FED ( ) 02 STATE ( 1 X�00^3 LOCAL <br /> !•� <br /> STREET ADDRESS CITY �. STATE IIP ZO 6 <br /> 36'731 Gel MERGE p2��� /j SAO' ANTONIO T* rA 78220 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/S RVISOR <br /> Ell I EMI FIST fiff-e4 -leRAND -,i✓Lm1�r+�-LLQ/ <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 501 W LODI HUTCHINS <br /> CITY COUNTY <br /> ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITY 1 STATE ZIP <br /> P a 9PE, z_��» Dn. IO �j/0��. �7t` 78t2Dtlr2�6 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 512-223-3131 'L p 2-o/ (X) 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER OF CONTAINERS RVRAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 3 <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 /> JORDAU -8*RT 916-427-2718 JO 916-685-7288 <br /> i Zv� �;V,?-2-G:1 20y o-"// <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM/ FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. IX) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER O08 <br /> B. MANUFACTURER (.IF APPROPRIATE): UNKNOWN YEAR MFG: C. YEAR INSTALLED 1972 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 9940 GALLONS ( 7 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 ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED (X) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( 1 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 ( ) 02 SINGLE WALLED f ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( 1 08 BRONZE ( ) 09 COMPOSITE f ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />