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'v <br /> STATE ID NUMBER 00000034927004 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( O1 NEW PERMIT ( ) 05 RENEWED PERMIT ( 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> TT"02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(CCPPCP.ATION,INOIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CITY OF LODI ( ) 01 FED ( ) 02 STATE 00 03 LOCAL <br /> STPEET ACDPESS CITY STATE ZIP <br /> 221 W. PINE ST LODI CA 95240 <br /> II FACILITY <br /> FACILITf NAME �( L ^ 1 5, � DEALEP./FOREMAN/SUPEPVISOP <br /> ER v f'� m ( 1 .. � OMER COULTER) M h�ek�Kc� s er Vl-so it <br /> STEEET ADDPE NEAREST CROSS STREET <br /> 1331 S. HAM LN. KETTLEMAN <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95241 <br /> (LING ADDRESS CITY STATE ZIo <br /> 221 W. PINE ST. LODI CA 95240 <br /> PHCNE W./AREA CCDE TYPE OF BUSINESS <br /> 209-334-5634 ( ) 01 GASOLINE STATION (X) 02 OTHER VEHICLE MAINT. <br /> NU SEP CF CONTAINERS PUPAL AREAS ONLYTOWNSHIP RANGE SECTION <br /> 4 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME( LA.ST NAME FIRST) .AND PHONE W/AREA CODE NIGHTS: N.AME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> LODI FIRE DEPT 209-369-3531 SAME - <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK [ ) 04 OTHER: CONTAINER NUMBER 1331f/A <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1972 C. YEAR INSTALLED 1972 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 5000 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 ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM (X) Q�4_ EL ( ) 05 WASTE OIL ( l 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1/4 ( ) GAUGE (X) INCHES ( ) CM ( l 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. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( ) 03 FIBERGLASS t ) 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br />