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STATE ID NUMBER 00000020285003 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> fx) 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CORPORATION,ZNDIVIDU�.AyL) OR PUBLIC/AGENCY) PUBLIC AGENCY ONLY <br /> AUT TR^ .. <br /> -.- -• -._./�) / l,Ccup� � '1Jtl('. ( ) 01 FED ( ) 02 STATE f ) 03 LOCAL <br /> STREET ADDRESS <br /> r <br /> 3643 E. COMMERCE 2191 S TANYAN*BHI9 STDG ICTO,j STATEIn 9rZb6 <br /> IIP <br /> 7ei'L 78fE9' <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/S PERVISOR <br /> FILL-EM+-FAST-#M2-^64 �,/ yj / <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 501 W LODI HUTCHINS <br /> CITY COUNTY <br /> ZIP <br /> LODI SAN JOAQUIN 95240 <br /> MAILING ADDRESS �( q CITY <br /> P.0�0»4#T� 91 ( / A� . SaH-*HTO D 514 C �- FNr TE X18220 a� <br /> G4 S�2 <br /> PHONE W/APEA CODE �+ TYPE OF BVSI NESS <br /> Ie? `(,?2p// (X) 01 GASOLINE STATION ( 1 02 OTHER <br /> NUMBER OF CONTAINERS RURAL 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 /> l9RB*MT'-eARY' 9it6=427=2m JDRDAN,-GARY685-7288 <br /> C>D (-ALIO/ `/V3 Zo/l mEf 916-/ -LC// <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORfl FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 104 OTHER: CONTAINER NUMBER B.i6 <br /> B. MANUFACTURER (IF APPROPRIATE): UNKNOWN YEAR MFG: C. YEAR INSTALLED 1972 ( 1 UNKNOWN <br /> D: CONTAINER CAPACITY: $y6D. 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 f l 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> ( ) 01 UNLEADED ( ) 02 REGULAR (X) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED l)<) 02 SINGLE WALLED ( ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS f ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE f 1 10 NON-METALLIC <br /> f ) 12 UNKNOWN ( ) 13 OTHER: <br /> MSC04-070185 (10/18/85) PAGE 1 <br />