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STATE ID NUMBER 00000009960001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> O1 NEW PERMIT t 1 05 RENEWED PERMIT ( ] 07 TANK CLOSED <br /> t 1 09 DELETE FROM FILE <br /> (NO FEE] <br /> ( ) 02 CONDITIONAL PERMIT i 1 06 AMENCED PERMIT ( 1 08 MINOR CHANGE tN0 SURCHARGE) <br /> I OWNER <br /> NAME(CORPOPATION.INDIVIDUAL OR PUBLIC AGENCY) _ PUBLIC AGENCY ONLY <br /> ( 1 <br /> 01 FED ( 1 02 STATE [ ) 03 LOCAL <br /> GEORGE GEMELLOS, I <br /> CITY STATE ZIP <br /> STREET ADDRESS LODI CA 952409294 <br /> 3049 W. HWY 12 <br /> II FACILITY <br /> FACItITY NAME DEALER/FOREMAN/SUPERVISOR <br /> IDLEWILD MARKET SELF <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 3049 W. HWY 12 DEVRIES RD. <br /> CIT'f COUNTY ZIP <br /> LODI SAN JOAQUIN 952409294 <br /> MAILING ADDRESS CITY STATE ZIP <br /> SAME AS ABOVE LODI CA 952409294 <br /> PHONE W/ARE.A CODE TYPE OF BUSINESS <br /> 209-369-2057 [ ) 01 GASOLINE STATION (X) 02 OTHER GROCERIES/GAS <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP =6EAF <br /> SECTION <br /> 2 3NO SOU <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 /> GEMELLOS, GEORGE 209-369-2057 SAME - _- <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION -_ - <br /> A. (XI 01 TANK ( 1 04 OTHER.' CONTAINER NUMBER #1 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED (X) UNKNOWN <br /> D. CONTAINER CAPACITY: 525 GALLONS ( I 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 ( 102 NO IF YES CHECK APPROPRIATE BOX(ESI: <br /> [Xl 01 UNLEADED ( 1 02 REGULAR t ) 03 PREMIUM [ ) 04 DIESEL ( ) 05 WASTE OIL ( ] 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT [ ) GAUGE [ 1 INCHES t 1 CM (X) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ] 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. t 1 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( 1 03 LINED <br /> D. ,f 1 01 CARBON STEEL i 1 02 STAINLESS STEEL ( ) 03 FIBERGLASS [ 1 04 POLYVINYL CHLORIDE ( l 05 CONCRETE <br /> t ) 06 ALUMINUM (X) 07 STEEL CLAD f ] 08 BRONZE ( ) 09 COMPOSITE € 1 10 NON-METALLIC <br /> t 1 12 UNKNOWN ( ) 13 OTHER: <br /> PAGE 1 <br /> HSC04-070185 (10/18/85) <br />