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STATE ID NUMBER 00000024934002 <br /> APPLICATION FOR PERMIT TO OPERATEUNDERGROUND STORAGE TANK <br /> 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TAW CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( ) 02 CONDITIONAL PERMIT t ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPOPATION.INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> LODI MEMORIAL HOSPITAL ( ) 01 FED ( ) 02 STATE ( l 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 975 SO. FAIRMONT LODI CA 95240 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> LODI MEMORIAL HOSPITAL <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 975 SO. FAIRMONT —_ <br /> CITY COUNTY ZIP <br /> LODI SAN JOAQUN 43240 <br /> MAILING ADDRESS CITY STATE ZIP <br /> CALL BOX 3004' LODI CA 95241 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-334-3411 E ) 01 GASOLINE STATION (X) 02 OTHER HOSPITAL <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 2 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AP.EA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> BLAIS, JIM 209-334-3411 EUGINEER ON DUTY 209-334-3411 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: CONTAINER NUMBER 2 <br /> k <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED 1981 ( l UNKNOWN <br /> D. CONTAINER CAPACITY: 15000 GALLONS ( l 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 t 1 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM (X) 04 DIESEL ( ) 0'5 WASTE OIL ( , ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF 'PRIMARY CONTAINMENT: ( ) GAUGE t ) INCHES ( ) CM (X) 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 E ) 03 LINED <br /> D. (X) 01 CARBON STEEL ( ) 02 STAINLESS STEEL ( l 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( l 05 CONCRETE <br /> ( ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE E ) 09 COMPOSITE ( l 10 NON-METALLIC <br /> d 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (1'0/18/85) PAGE 1 <br />