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STATE ID NUMBER 00000054181001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 61) 01 NEW PERMIT ( ) 05 RENEWED PERMIT ( 1 07 TANK CLOSED t ) 09 DELETE FROM FILE (NO FEEL <br /> 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( } 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> NA.ME(COPPOPATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> RETIREMENT HOUSING FOUNDATION ( ) 01 FED ( ) 02 STATE t ) 03 LOCAL <br /> 255 S. HILL STREET, SUITE 407 STATE 2TR <br /> CI <br /> STPEET ADDRESS TY LOS ANGELES CA 90012 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPEPVISCR <br /> PLYMOUTH SQUARE DON WILLIAMS, ADMINISTRATOR <br /> S P!ET ADDRESS NEAREST CROSS STREET <br /> 1319 N. MADISON VINE ST. <br /> CITY <br /> COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95202 <br /> MAI-LING ADDRESS CITY STATE ZIP <br /> 1319 N. MADISON SAN JOAQUIN CA 95202 <br /> ?HCNE W/AREA COCEE TYPE =BUSINIESS <br /> 209-466-4341 [ 1 INE STATION (X) 02 OTHER RETIREMENT HOME <br /> N'JMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 1 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAPS: NAME(LAST N4ME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> BOLTON, DELMAR 209-931-6175 SAME _ <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( l 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): HOLT BROS. YEAR MFG: 1970 C. YEAR INSTALLED 1970 f 1 UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS ( ) UNKNOWN E. DOES THE CONTAINER STORE: ( ) 01 WASTE (X1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES [ l 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( 1 01 UNLEADED ( l 02 REGULAR ( l 03 PREMIUM (X) 04 DIESEL ( ) 05 WASTE OIL ( } 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: [ ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (ZI 02 NON-VAULTED 4*1 03 UNKNOWN <br /> C. ( l 01 DOUBLE WALLED ( l 02 SINGLE WALLED ( } 03 LINED <br /> D. 01 CARBON STEEL ( l 02 STAINLESS STEEL ( l 03 FIBERGLASS ( l 04 POLYVINYL CHLORIDE ( } 05 CONCRETE <br /> t ) 06 ALUMINUM ( l 07 STEEL CLAD t 1 08 BRONZE ( } 09 COMPOSITE f ) 10 NON-METALLIC <br /> ('E) 12 UNKNOWN f l 13 OTHER: <br /> HSC04-070185 (10/18/85) <br /> PAGE 1 <br />