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STATE ID NUMBER 00000034'7001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( ) <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT (N) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEtI <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( 1 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPOPATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> CITY OF LODI ( ) 01 FED ( ) 02 STATE I�L03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 221 W. PINE ST LODI CA 95240 <br /> II FACILITY J <br /> FACILITY N.=.ME - ! «'1 DEALER/FOP,EMAN/SUPERVISOR <br /> OMER COULTER <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 1331 S. A LN. KETTLEM.AN <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUIN 95241 <br /> MAILING ADOOESS CITY STATE ZIP <br /> 221 W. PINE ST. LODI CA 95240 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-334-5634 ( ) 01 GASOLINE STATION (X) 02 OTHER VEHICLE MAINT. <br /> NUMBEP OF CCNTAINEPS PUPAL AREAS ONLYTOWNSHIP RANGE SECTION <br /> 4 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAY'S: NAME(L.AST NAME FIRST) AND PHONE W!APEA 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 1331ye <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: 1972 C. YEAR INSTALLED 1972 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 500 GALLONS ( ) UNKNOWN JE. DOES THE CONTAINER STORE: (X) 01 WASTE ( ) 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 /> i <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( l 04 DIESEL (X) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: 1/4 [ ) GAUGE (X) INCHES ( 1 CM ( ) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( l 01 DOUBLE WALLED (X) 02 SINGLE WALLED ( 1 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL f 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( l 08 BRONZE ( 1 09 COMPOSITE ( l 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER; <br /> HSC04-070185 (10/18/85) PAGE 1 <br />