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• STATE ID NUMBER 00000018582001 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 4f ] O1 NEW PERMIT ( ) 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> 2 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> N4ME(COPFORATION,INDIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> MEM MASONRY INC. ( ) <br /> 01 FED ( ) 02 STATE ( ) 03 LOCAL <br /> STREET ADDRESS <br /> S <br /> 395 INDUSTRIAL WAY CITY TATE ZIP <br /> OIXON CA 95620 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> MEM MASONRY EDGAR MERTZ <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 33 MAXWELL STREET STOCKTON <br /> CITY <br /> COUNTY ZIP <br /> LOBI SAN JOAQUIN 95240 <br /> MAILING ADDRESS CITY STATE IIP <br /> 395 INDUSTRIAL WAY OIXON CA 95620 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 916-678-3071 ( ) 01 GASOLINE STATION (X) 02 OTHER MASONRY <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/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> MERTZ,. EDGAR q , _ <br /> .� -700-30 -71 MERTZ, EDGAR <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: CONTAINER NUMBER 1 <br /> B. MANUFACTURER (IF APPROPRIATE): UNKNOWN YEAR MFG: C. YEAR INSTALLED 1977 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 4000 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 /> (X) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( I INCHES ( ) CM (X) UNKNOWN <br /> B. fXl 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) ( ] 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( ) 02 SINGLE WALLED ( ] 03 LINED <br /> 0. (X) 01 CARBON STEEL ( 7 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE [ ) 05 CONCRETE <br /> f ) 06 ALUMINUM ( ) 07 STEEL CLAD ( ) 08 BRONZE ( ) 09 COMPOSITE ( ) 10 NON-METALLIC <br /> ( l 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/857 <br /> PAGE 1 <br /> i <br />