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STATE ID NUMBER 00000034927003 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> t X01 NEW PERMIT ( ) 05 RENEWED PERMIT ( l 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT ( l 06 AMENDED PERMIT ( l 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> N4ME(COPPORATION.ZNDIVI0UAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CITY OF LODI ( ) 01 FED ( ) 02 STATE Az--Y 03 LOCAL <br /> ST=EET ADDRESS CITY STATE ZIP <br /> 221 W. PINE ST LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME Lt DE.4LEP./F OREM.4N!SUPERVZSOR <br /> E 7 IF ER COULTER <br /> STPEET 40ORESS NEAREST CROSS STREET <br /> 1331 S. HAM LN. KETTLEMAN <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95241 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 221 W. PINE ST. LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-334-5634 ( l 01 GASOLINE STATION (X) 02 OTHER VEHICLE MAINT. <br /> NUMBER OF CCNTAINERS RURAL AREAS ONLYTOWNSHIP RANGE SECTION <br /> 4 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DA)S: NAME(LAST NAME FIRST) AND PHONE W/A.PEA CODENIGHTS: NAME(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 1331-3 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: I C. YEAR INSTALLED 147.2( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 5000 GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( l 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 /> (X) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( 1 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1/4 ( l GAUGE (X) INCHES ( ) CM ( ) UNKNOWN <br /> B. ( 1 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. t 1 01 DOUBLE WALLED (X) 02 SINGLE WALLED f ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( l 02 STAINLESS STEEL f l 03 FIBERGLASS ( 104 POLYVINYL CHLORIDE ( ) 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 />